SEASES 



LIBRARY OF CONGRESS. 



; %p lu^ng^l^- 



UNITED STATES OF AMERICA. 



THE PHYSICAL DIAGNOSIS 



OF THE DISEASES < >!■' 



THE HEART AND LUNGS 



AND THORACIC ANEURISM 



;■■■; 






D. M. V CAMMANN, B.A. Oxon., M.D. 



W 







G. P. PUTNAM'S SONS 

NEW YORK LONDON 

27 WEST TWENTY-THIRD ST. 27 KING WILLIAM ST., STRAND 

3% fmickirbotktr |}ks8 
1891 




Copyright, 1891 

BY 

D. M. CAMMANN, B.A. Oxon., M.D. 



Ube Tknfcfccrbocfeer press, IRevv lBorft 

Electrotyped, Printed, and Bound by 
G. P. Putnam's Sons 



In Memoriam 
G. P. C 

AND 

M. M. W. 



CONTENTS. 



PAGE. 

PREFACE , xi. 

THE LUNGS. 

SECTION I. 

EXAMINATION OF THE CHEST . . . . I 

REGIONS OF THE CHEST 2 

POSITION OF THE LUNGS AND OTHER ORGANS . 5 

INSPECTION . . . . . . . -9 

PALPATION 12 

MENSURATION 14 

SUCCUSSION . . . . . . -15 

PERCUSSION IN HEALTH . . . . 1 5 

Position in Examination — General Remarks — 
How to Percuss — Varieties of Percussion Reso- 
nance — Percussion over the Normal Chest. 

AUSCULTATION IN HEALTH 21 

Immediate and Mediate Auscultation — How 
to Auscultate — Stethoscopes. 

CHEST ACOUSTICS 3 1 

Elements of Sound — Consonance — Unison 
Resonance — Echo. 

RESPIRATION IN HEALTH VOCAL RESONANCE . 37 



CONTENTS. 



SECTION II. 

PERCUSSION IN DISEASE — RESPIRATORY PERCUSSION, 

AUSCULTATION IN DISEASE 

Respiratory and Vocal Sounds — Rales — Ad- 
ventitious Sounds in the Chest Wall — Facts and 
Theories in Regard to the Origin of Rales. 



PAGE 

44 



SECTION III. 



ACUTE BRONCHITIS 










. 66 


CHRONIC BRONCHITIS 










66 


CAPILLARY BRONCHITIS 










• 67 


LOBAR PNEUMONIA 










. 68 


LOBULAR PNEUMONIA 










• 7o 


PLEURISY 










• 7* 


EMPYEMA 










• 75 


HYDROTHORAX 










• 75 


HYDROPNEUMOTHORAX 










• 76 


PNEUMOTHORAX 










• 77 


EMPHYSEMA 










• 78 


ASTHMA . 










• 79 


PULMONARY CEDEMA 










. 80 


HAEMOPTYSIS . 










. 81 


PULMONARY CONGESTION 








• 83 


ACUTE MILIARY TUBERCULOSIS 






• 83 


PULMONARY PHTHISIS 






• H 


ATELECTASIS AMD PULM 


DNAR 


Y CO 


LLAPS 


>E 


• 96 



CONTENTS. 



PULMONARY INFARCTION 
PULMONARY APOPLEXY . 
PULMONARY GANGRENE . 
PULMONARY CANCER 



THE HEART. 



SECTION IV 
POSITION OF THE HEART 
INSPECTION 
PALPATION 

PERCUSSION 
AUSCULTATION 

General Remarks 



Sounds of the Heart — 
Intermittence and Irregularity — Paralysis of the 
Heart — Reduplication of the Heart Sounds. 



AUSCULTATORY PERCUSSION 



General Rules — Table of Averages of Male 
Hearts. 

SECTION V. 



General Remarks — Pericardial Murmurs — 
Valvular Murmurs — Aortic Obstruction — Aortic 
Regurgitation — Mitral Regurgitation — Mitral 
Obstruction — Pulmonary Systolic Murmur — 
Pulmonary Regurgitant Murmur — Tricuspid 
Regurgitation — Tricuspid Obstruction — Intra- 
ventricular Murmur — Anaemic Murmur — Com- 
bination of Murmurs — Variability of Murmurs. 



I02 

117 
118 
123 



•37 



145 



viil CONTENTS. 

SECTION VI. 

PAGE 

PERICARDITIS l6o 

ADHERENT PERICARDIUM ..... 163 

HYDROPERICARDIUM 1 64 

HYPERTROPHY . . ... . . I 64 

DILATATION . . . . . . .165 

FATTY DEGENERATION AND INFILTRATION . . 166 

ANEURISM OF THE THORACIC AORTA . . . 167 

VENOUS MURMURS, CONGESTION, AND PULSATION . 1 73 

THE PULSE 174 

THE SPHYGMOGRAPH 1 76 



ILLUSTRATIONS. 



FIGURE PAGE 

I. — Showing Position of Heart, Lungs, and Great Vessels. 

(Sibson) 5 

2. — Showing Bifurcation of Trachea and Position of Main 

Bronchi. (Sibson) ...... 7 

3&4. — Monaural Stethoscopes ...... 22 

5. — Cammann's Binaural Stethoscope ..... 23 

6. — Cammann's Modified Chest-piece ..... 24 

7. — Alison's Differential Stethoscope ..... 26 

8. — Cammann's Binaural Hydrophone for Auscultatory Per- 
cussion ......... 28 

9. — Cammann's Intracostal Solid Cedar Stethoscope . . 29 

10. — Showing Position of Heart and Great Vessels. (Quain's 

"Anatomy") . . • . . . . . 103 

II. — Showing Heart, Great Vessels, Diaphragm, etc., Ex- 
posed. (Sibson) ....... 105 

12. — Side View of Heart and Great Vessels. (Sibson) . . 107 
13. — Right Auricle and Ventricle Exposed Showing Valves. 

(Quain's " Anatomy ") 109 

14. — Base of Ventricular Part of Heart, Showing Relative 
Position of the Arterial and Auriculo-Ventricular 
Orifices. (Quain's "Anatomy") . . . .110 



X ILLUSTRA TIONS. 

FIGURE PAGE 

15. — Heart and Vessels as Seen from Behind. (Sibson) . in 
16. — Cammann's Cardiometer . . . . . .116 

17. — Diagrammatic Representation of Systolic and Diastolic 

Murmurs. (Bramwell) 149 

18. — Diagrammatic Representation of Systolic and Presystolic 

Murmurs. (Bramwell) ...... 149 

19. — Diagrammatic Representation of Systolic, Diastolic, and 

Presystolic Murmurs. (Bramwell) .... 149 
20. — Pericardium Containing Fifteen Ounces of Fluid. 

(Sibson) 161 

21. — Pericardium Containing ^ Pound of Fluid. (Sibson) . 161 
22. — Dudgeon's Sphygmograph . . . . .177 



PREFACE. 

This little book is the result of a series of 
notes originally thrown together for my own 
instruction and assistance in teaching. By 
arranging them under proper headings, and 
adding here and there fresh matter, it is hoped 
that a work has been prepared that may be of 
some value. Although I have endeavored to 
make this a text-book on the physical diag- 
nosis of diseases of the heart and lungs, it is 
in one sense fragmentary, as some questions 
which have especially interested me, or on 
which a reasonable difference of opinion ex- 
ists, have been considered more in detail than 
is usual in such a work. 

The author's modification of the Cammann 
stethoscope and the binaural hydrophone are 
given more space than from their intrinsic 
value they deserve. This is not done from 
any over-estimation of their relative import- 



xii PREFACE. 

ance, but because it is believed to be an 
author's privilege to fully explain his own 
ideas. 

The averages of the measurements of the 
heart by auscultatory-percussion are from tables 
made by my father, the late Dr. G. P. Cam- 
mann, and have heretofore only been published 
in part. 

The importance of a knowledge of acoustics 
to the student in physical diagnosis is not suffi- 
ciently recognized. A field is opened in this 
direction which will repay exploration and 
assist greatly in the correct interpretation of 
physical signs. It has been my endeavor to 
emphasize this in the following pages. 

A large number of books and medical jour- 
nals have been consulted, and if reference were 
made to each from which assistance has been 
obtained, these pages would be overloaded 
with references. I make this general acknowl- 
edgment and excuse for their omission. 



D. M. CAMMANN. 



19 East 33D Street, 
New York. 



THE PHYSICAL DIAGNOSIS 

OF THE 

DISEASES OF THE HEART AND LUNGS. 
THE LUNGS. 



SECTION I. 

EXAMINATION OF THE CHEST. 

In many cases of disease we can arrive at a 
correct knowledge of the condition of the 
patient without employing all the methods of 
physical diagnosis, but it is best always to 
make a systematic examination of all parts of 
the chest, and to use every means which may 
aid us in diagnosis. In the majority of cases 
it is not any one physical sign, but the group- 
ing- together of several which indicates the 
true condition of the parts under examination. 
Now and then we are obliged to remain in 



2 DISEASES OF THE HEART AND LUNGS. 

doubt and await future development before 
reaching a positive diagnosis, but the number 
of such cases is not large, and a careful exam- 
ination will clear up many doubtful points. 

REGIONS OF THE CHEST. 

Authors have divided the chest into regions 
in various ways. The divisions are of no great 
importance, as the many bony landmarks over 
the thorax furnish a ready means of locating 
physical signs. 

The following is the division usually given : 

Supraclavicular Region. — The shape is tri- 
angular. The inner boundary is the edge of 
the trachea ; the upper, a line from the outer 
third of the clavicle to the upper rings of the 
trachea ; the lower, the clavicle. 

Clavicular Region. — The region comprises 
the inner two-thirds of the clavicle. 

Infraclavicular Region. — The region is 
bounded by the clavicle above and the lower 
border of the third rib below ; inside by the 
edge of the sternum, and outside by a vertical 
line from the junction of the middle and outer 
third of the clavicle. 



EXAMINATION OF THE CHEST. 3 

Mammary Region. — Bounded above by the 
lower border of the third rib ; below by the 
lo.ver border of the sixth rib; inside by the- 
sternum, and outside by a line continuous with 
the outer boundary of the infraclavicular 
region. 

Inframammary Region. — Bounded above by 
the sixth rib ; below by the edges of the false 
ribs ; inside by the sternum, and outside by 
the prolonged outer boundary of the mam- 
mary region. 

Suprasternal Region. — The space above the 
notch of the sternum. 

Upper Sternal Region. — The portion of the 
sternum lying above a line joining the lower 
borders of the third ribs. 

Lower Sternal Region. — The sternum below 
the lower border of the third ribs. 

Axillary Region. — Bounded by the axilla 
above ; below by a line continuous with the 
lower border of the mammary region ; in front 
by the outer border of the infraclavicular and 
mammary regions ; behind by the external 
edge of the scapula. 

Infra-axillary Region. — Bounded above by 



4 DISEASES OF THE HEART AND LUNGS. 

the axillary region ; below by the edges of the 
false ribs ; in front by the inframammary, and 
behind by the infrascapular regions. 

Suprascapular and Scapular Regions. — 
These have the same boundaries as the fossa? 
of the scapula. 

Interscapular Region. — Bounded inside by 
the spines of the dorsal vertebrae ; outside by 
the inner edge of the scapula ; above by the 
second and below by the sixth ribs. 

Infrascapular Region. — Bounded above by 
the inferior angle of the scapula and the 
seventh dorsal vertebra ; below by the twelfth 
rib ; outside by the posterior edge of the infra- 
axillary region ; inside by the spine. 

POSITION OF THE LUNGS AND OTHER ORGANS. 

In the supraclavicular region are found the 
apex of the lung, the subclavian and carotid 
arteries, and the subclavian and jugular veins. 
On the right side, in front; the border of the 
lung extends almost vertically near the median 
line to the sixth rib, where it takes an abrupt 
turn, the lower border lying about on a level 
with the sixth rib, but varying in position from 




Figure i. 
showing position of heart. lungs, and great vessels. (sibson.) 



6 DISEASES OF THE HEART AND LUNGS. 

an inch to an inch and a half with respiration. 
The upper border of the liver, covered by the 
right wing of the diaphragm, extends as high 
as the fourth rib, the lung becoming thinner 
from this point down to its sharp edge. Be- 
hind the right sterno-clavicular articulation is 
the innominate artery, while the subclavian 
artery crosses at the outer edge of the clavicu- 
lar region. The main bronchus — wider, shorter, 
and less oblique than the left — lies behind the 
second costal cartilage, while running close to 
the sternal border are the superior cava and 
arch of the aorta, and below the heart extends 
about an inch to the right of the sternum. 

The notch above the sternum contains the 
trachea, and at the lower right side the innomi- 
nate artery. In some persons the arch of the 
aorta reaches into this space. Over the upper 
sternal region the lungs nearly touch, and 
behind lie the ascending and transverse por- 
tions of the arch of the aorta ; the pulmonary 
arterv from its origin to the bifurcation ; the 
aortic and pulmonary valves ; and at the level 
of the second ribs the trachea with its bifurca- 
tion. Behind the lower sternal reeion are a 






? ;:V"" 



% 



Figure 2. 
showing bifurcation of trachea and position of main bronchi. 

(SIBSON.) 



8 DISEASES OF THE HEART AND LUNGS. 

part of the heart, and below a portion of the 
liver and sometimes of the stomach. 

On the left side, the edge of the lung lies 
behind the sternum, and, extending downward 
and outward from about the fourth costal 
cartilage, leaves the heart uncovered over a 
space of variable size, and, reaching the fifth 
rib, crosses downward and inward to the sixth 
rib. Behind the clavicle, and deeply seated 
and almost at right angles with the bone, are 
the carotid and subclavian arteries. A little 
below the second costal cartilage lies the main 
bronchus, while in front, at the edge of the 
sternum, is the pulmonary artery. The base 
of the heart lies behind the lower border of the 
third rib. The heart is superficial as we pass 
downward. The lower part of the inframam- 
mary region is occupied by the stomach, the 
anterior edge of the spleen, and a portion of 
the left lobe of the liver. 

The axillary and infra-axillary regions con- 
tain the lungs, and below, on the right side, the 
liver, and on the left the spleen and stomach. 

The lung occupies the regions in the pos- 
terior portion of the chest, the lower border 



EXAMINATION OF THE CHEST. 9 

extending to the tenth rib, the left lung reach- 
ing a little lower than the right, and both 
varying in position considerably during respira- 
tion. The main bronchus and bronchial glands 
are contained in the region between the scap- 
ula and spine, and on the left side the oesoph- 
agus and descending aorta. The bifurcation 
of the trachea is in the median line, with some 
inclination to the right. On the right side, 
below the tenth rib, is the liver, and on the 
left side intestines at the inner and the spleen 
at the outer part. Close to the spine, and 
more on the left than on the right, the kidney 
encroaches on this region. 

INSPECTION. 

A matter of no little importance is that 
the patient be in a good light, so that the 
whole chest is clearly seen. In a systematic 
examination, first look carefully over the 
chest for any thing wrong about the skin, or 
deformity in shape. The healthy adult chest 
measures more transversely than in the antero- 
posterior diameter. This proportion may be 
reversed, as in those who are " pigeon- 



IO DISEASES OF THE HEART AND LUNGS. 

breasted," without being necessarily associated 
with a diseased condition of the lungs. In 
children the two diameters are nearly equal, 
so that the chest is almost circular. The two 
sides should be nearly symmetrical and expand 
equally. In right-handed persons the right 
side is usually somewhat the larger, the 
reverse being the case in the left-handed. 
Respirations vary in a healthy chest from six- 
teen to twenty per minute, and expiration is 
shorter than inspiration. In children the 
breathing is more rapid. The average rate at 
birth is forty-four per minute, and at five years 
of age twenty-six, which becomes reduced to 
the average frequency between fifteen and 
twenty years of age. In males the expansion 
of the upper is not as marked as of the lower 
part of the chest and abdomen (abdominal 
respiration) ; in females the upper part ex- 
pands more (thoracic respiration), and this 
difference between the sexes is much increased 
by the tight corsets so universally worn by 
women. 

Do not be deceived by rapid breathing, 
which is not always the result of thoracic 



EX AM IN A TION OF THE CHEST. II 

disease. Differences in position or in degrees 
of activity, functional nervous disorders, peri- 
tonitis, the pressure of abdominal tumors, 
ascites, paralysis of the diaphragm, or gas in 
the intestines influence the rapidity, or the 
respirations may be slow and labored or irregu- 
lar from lesions of the cerebro-spinal system. 

Notice particularly flatness or bulging of the 
chest wall or of the intercostal spaces. Re- 
traction and want of free motion over one or 
both sides lead us to suspect the presence of 
old pleuritic adhesions. Pleuritic adhesions, 
however, may be present over limited areas on 
one or both sides, and cripple the lungs to a 
considerable degree without occasioning any 
marked retraction. In acute pleurisy, expan- 
sion over the affected side is often almost 
entirely lacking owing to the pain excited by 
every effort at respiration. But pain alone, 
from pleurodynia or from intercostal neuralgia 
without any lesion of the lung or pleura, may 
produce the same result. When respiration is 
painful the pleuritic adhesions are not put on 
the stretch, or the friction between the two 
surfaces of the pleura is reduced to a mini- 



12 DISEASES OF THE HEART AND LUNGS. 

mum, and the pleurisy may be easily over- 
looked. A bulging of the lower part of the 
chest and a widening of the intercostal spaces 
indicates the presence of a considerable amount 
of fluid in the pleural cavity, while if the 
whole chest, and more especially the upper 
half, is bulging and rounded or " barrel- 
shaped," emphysema is certainly present. An 
obstruction in the larynx causes a sinking in 
of the intercostal spaces during inspiration. 
In health the veins are not usually visible be- 
neath the skin, but in certain conditions, not 
necessarily connected with disease of the lungs, 
the veins of one or both sides may be promi- 
nent. 

PALPATION. 

Palpation is chiefly useful in confirming 
knowledge acquired by other means, but some- 
times in doubtful cases the hand assists us in 
reaching a correct diagnosis. By its aid we 
estimate the expansion of the chest, the char- 
acter of vibrations and impulses, and the tensity 
and size of tumors. 

When the intercostal spaces over the lungs 
are gently tapped with the tip of the finger a 



EXAMINATION OF THE CHEST. 1 3 

feeling of springiness or elasticity is experi- 
enced, and over the liver a sense of resistance 
from the solid organ beneath. This resistance 
or elasticity varies with changes in the lung 
tissue or in the pleura. In children and in 
thin persons the elasticity is most marked. 

By causing the patient to speak when the 
hand or the ear is placed on the chest, we feel 
the vibrations of the voice, the vocal fremitus, 
with more or less distinctness through the 
chest wall. The vocal fremitus is naturally 
most marked in the upper anterior portions of 
the chest, in the lateral regions, and behind 
and below the scapulae. As so many condi- 
tions influence the conduction of sonorous 
vibrations in the chest, as, for example, the 
diseased condition of the lungs or pleurae, also 
the loudness or coarseness of the voice, and as 
vocal fremitus depends upon such conduction, 
a slight difference in the two sides, without 
the presence of other physical signs, cannot be 
taken as evidence of a diseased condition of 
the lung. Vocal fremitus is naturally more 
marked under the right than under the left 
clavicle, and not uncommonly is more pro- 



14 DISEASES OF THE HEART AND LUNGS. 

nounced over the whole of the right than over 
the left lung. 

MENSURATION. 

Mensuration is useful when we wish to 
keep an accurate record of cases or com- 
pare the expansion of the chest from time 
to time. Measurements should always be 
made at the same level so as to be available 
for purposes of comparison. A convenient 
level is at the sixth costo-sternal articulation 
between the vertebral spinous processes and 
the median line in front. 

We must remember that in health the two 
sides of the chest vary considerably, and that 
in right-handed persons the right side is half 
an inch or more wider than the left. To com- 
pare the two sides it is necessary that the 
measurements be taken during the same stage 
of respiration in both, and the best time is 
when the patient holds his breath at the end of 
expiration. 

A number of instruments have been invented 
for estimating the expansion of the chest 
during the respiratory act. 



PERCUSSION. 15 

SUCCUSSION. 

Succussion is almost exclusively employed 
in one disease, pneumo-hydrothorax. It con- 
sists in giving the trunk of the patient a slight, 
quick shake while the ear is applied to the chest. 

PERCUSSION. 

Position in Examination. — For the back, 
fold the arms over the chest, clasping the 
shoulders with the hands, and bend slightly 
forward. For the front, clasp the elbows with 
the hands behind the back. For the lateral 
regions, clasp the hands over the head. In 
this way the muscles are made thinner and 
firmer and transmit sound best. Always see 
that the position of both sides is the same. 
The stage of respiration should be noted when 
comparing the two sides, as the percussion note 
varies with the amount of air in the lungs and 
with the degree of tension of the lung tissue. 

Avenbrugger introduced the method of per- 
cussion about the middle of the last century, 
but through the labor of Corvisart, nearly 
thirty years later, it first became generally 
known. Now its practice is general, and skill 



1 6 DISEASES OF THE HEART AND LUNGS. 

in its use is by many supposed to be easily ac- 
quired, yet no less an authority than Laennec 
has told us that " percussion yields exact re- 
sults in the hands of those only who bring to 
its exercise experience, dexterity, and much 
attention." In fact, one skilled in percussion 
can at pleasure elicit a good resonance or a 
dull sound over a chest perfectly healthy. The 
same result is often involuntarily obtained by 
the unskilful ; some cannot elicit sufficient 
sound without striking hard enough to give 
the patient pain. The fingers are the best 
instruments for percussion, and with them too 
it is easy at the same time to measure the re- 
sistance or the elasticity of the underlying tis- 
sue. Apply the palmar surface of the third 
phalanx of a finger of one hand directly to the 
skin, the rest of the finger being raised above 
the surface. In this way we obtain the per- 
cussion note over a smaller area than if the 
entire length of the finger is laid upon the 
chest. With a little practice the finger can be 
bent sufficiently. With one or two fingers of 
the other hand strike perpendicularly, gently, 
and quickly, keeping the fingers bent but im- 



percussion. iy 

movable, and giving the blow from the wrist, 
as you would strike the key of a piano. Do 
not strike hard. Usually in the normal chest 
a light tap is sufficient to elicit the percussion 
note. When the chest-wall is thicker than 
common, or the costal cartilages rigid and less 
vibratile, forcible percussion may be required, 
but this is equally true for superficial as for 
deep-seated parts. The finger should be 
placed parallel to the ribs, but when the inter- 
costal spaces are narrow, or the fat or muscles 
covering the ribs are thick, this is not of much 
importance. Do not go on hammering too 
long, but compare by two or three quick 
strokes each region with the corresponding 
region on the other side. Over the clavicles 
we may practise immediate percussion — that is, 
strike directly upon the bone without the in- 
tervention of a pleximeter. Bear in mind that 
the main point you want to find out by percus- 
sion is whether one part of the pulmonary 
tissue is more solid than another. If you any- 
where find a change in the percussion note, 
percuss around that spot and mark out the ex- 
tent of the abnormal resonance. 



1 8 DISEASES OF THE HEART AND LUNGS. 

Varieties of Percussion Resonance. — Over the 
normal chest and abdomen are obtained dul- 
ness, flatness, pulmonary resonance, and tym- 
panitic resonance. 

Pulmonary Resonance is heard over healthy 
lung. It is a low-pitched sound of variable 
intensity and considerable duration. Its quality 
is pulmonary. The percussion note will vary 
considerably even with the lungs in a normal 
condition, owing to the difference of elasticity 
of the chest-walls, and the varying thickness 
of the superficial tissues, so that each chest 
may be said to have its own normal percussion 
note, which differs more or less from all 
others. 

Dulness. — The quality is imperfectly pul- 
monary, and the pitch is high but has wide 
limits of variation. The duration varies with 
the pitch. The intensity is not great. It 
always indicates the presence of air. There is 
a sense of resistance to the percussing finger. 1 

1 The terms dulness and flatness as understood in this work are by 
some authors included under the common term dulness. In the 
latter case great dulness or extreme dulness is equivalent to flatness. 
Dulness as here understood may be slight and approach pulmonary 
resonance on the one hand, or it may be high-pitched and approach 



PERCUSSION. 19 

Flatness. — The quality is flat. It is a high- 
pitched sound of short duration and feeble 
intensity. Typical flatness is obtained by per- 
cussing the thigh. It indicates a body free 
from air, and is heard over the solid viscera. 
The resistance to the percussing finger is 
greater than in dulness, and depends upon the 
firmness of the body percussed. 

Tympanitic Resonance. — The quality is tym- 
panitic. The pitch varies and the intensity is 
considerable. To produce tympanitic reso- 
nance requires a cavity of considerable size 
filled with air which is not in a condition of 
high tension. It is heard over the stomach 
and intestines. 

Sternal Resonance. — It is a variety of pul- 
monary resonance, but of higher pitch and 
greater intensity. The sternum acts as a 
sounding-board, intensifying the sounds pro- 
duced by percussing over it. 

Percussion over the Normal Chest. — Per- 
cussion over the healthy chest elicits dulness 

flatness on the other, and it will therefore be readily perceived that 
the term includes a pretty wide range. It would be advantageous if 
some standard could be fixed of different degrees of dulness, to 
which all variations could be referred. 



20 DISEASES OF THE HEART AND LUNGS. 

in the supraclavicular region. Over the 
clavicle we obtain pulmonary resonance 
slightly modified by the bone. The infra- 
clavicular region yields pulmonary resonance, 
and is usually taken as the standard for com- 
parison with sounds heard over other parts of 
the chest. The pitch is somewhat higher on 
the right than on the left side, and on both 
sides immediately under the clavicle than 
over the second rib. In the right mammary 
region is dulness over the liver from the 
fourth rib, increasing on passing downward, 
and similarly on the left side, dulness over the 
heart, increasing from the third rib downward. 
The inframammary region gives flatness on 
percussion on both sides, changing to dulness 
over the upper portion when the lungs are 
fully expanded, and on the left side we may 
have tympanitic resonance from the stomach. 
Over the upper part of the sternum we have 
pulmonary resonance, somewhat modified by 
that bone, and on passing downward the pitch 
is raised by the heart and great vessels which 
produce dulness. In the axillary regions is 
pulmonary resonance on the right side down 



A USCUL TA TION. 2 1 

to the fifth rib ; from the fifth to the seventh, 
dulness ; and below the seventh to the free 
border of the ribs, flatness ; on the left side, 
pulmonary resonance to the seventh rib ; 
below, flatness. Behind, dulness in the scapu- 
lar and suprascapular regions, and pulmonary 
resonance in the interscapular and infrascapu- 
lar regions. 

AUSCULTATION. 

Auscultation of the respiratory and voice 
sounds may be practised with the ear, and is 
then called immediate, or with the stethoscope, 
when it is called mediate auscultation. If the 
ear alone is used, only a single layer of cloth- 
ing should cover the chest. The ear should 
be applied gently and firmly, allowing the 
head to rise and fall with the respiration. By 
pressing the side of the head as well as the 
ear against the chest, the hearing is rendered 
more acute, although the physical signs are 
not so well localized. 

The credit of bringing the stethoscope into 
practical use belongs to Laennec. He hit 
upon the idea accidentally by using a roll of 



22 DISEASES OF THE HEART AND LUNGS. 




paper held in his hand. The stethoscope of 
Laennec, which was nothing but a long hollow 

tube open at 
both ends, has 
been much 
modified in 
figure 3. shape, but the 

MONAURAL STETHOSCOPE. principle TQ- 

mains the same, the binaural being nothing 
more than the monaural adapted for the use 
of two ears instead of one. The principle of 
the telephone has lately been utilized for the 
stethoscope. 

Hollow stethoscopes are best for listening 
to sounds produced over the lungs. Solid 
cedar stethoscopes are useful for purposes of 
auscultatory percussion, but the binaural 
instrument will answer nearly as well. The 
best binaural stetho- 
scope is the one in- 
vented by Dr. G. P. 
Cammann. It is 
light, durable, easily 
carried, and a good conductor of sound. The 
attachment of a rim of soft rubber, as de- 




FlGURE 4. 
MONAURAL STETHOSCOPE. 



A USCUL TA TION. 2 3 

vised by Dr. Snelling, is of advantage in 
some cases for applying it more closely to the 
inequalities of the chest. Oval chest-pieces 
are also made which enable the end of the 
stethoscope to be pressed into the intercostal 
spaces. In the latest instruments the rubber 
band is replaced by a spring concealed in the 
screw which binds the two tubes of the steth- 
oscope together. 



Figure 5. 
cammann's binaural stethoscope. 

A modification of the chest-piece of Cam- 
mann's binaural stethoscope was devised by 
the author. The instrument differs from the 
latter in this, that in the chest-piece is a circu- 
lar chamber open on the side applied to the 
chest. The inner and outer walls of this 
chamber are circular and nearly half an inch 
apart, the inner wall being the expanded ex- 
tremity of the tube leading from the chest to 



24 DISEASES OF THE HEAkT AND LUNGS. 

the ears, and the outer being the outer wall of 
the chest-piece, which, arching above and join- 
ing the inner wall, forms the roof of the cham- 
ber. The rims of the inner and outer walls lie 
in the same horizontal plane, so that when the 




Figure 6. 
cammann's modified chest-piece. 

instrument is applied to the chest the chamber 
is closed on every side. Connected by a 
small tubular opening with this chamber is a 
hollow rubber bulb, and by pressure and 
relaxation of pressure by the hand upon this 
bulb, the air in the hollow chamber is 



A USCUL TA TION. 2 $ 

exhausted, and the stethoscope is held against 
the chest by the pressure of the external air. 
The tube conveying the sounds to the ear 
passes through the rubber bulb just above the 
chest-piece. The advantages of this are two- 
fold : it gives compactness to the instrument, 
and the rubber bulb acts as a resonator to the 
passing sounds. 

Some of the practical advantages in the use 
of the modified chest-piece are that it is 
brought into the closest possible contact with 
the chest wall, and that the sounds conveyed 
to the ear pass through two hollow chambers, 
the one in the chest-piece and the rubber 
bulb, both of which act as resonators and 
increase their intensity. Not only is the in- 
tensity of the sound greater than with the ordi- 
nary stethoscope, but the true quality is better 
brought out. The heart sounds are more 
intense and the murmurs more readily recog- 
nized. The bronchial sounds are more bron- 
chial, and the true character of sounds heard 
over cavities is better appreciated. Another 
advantage of the instrument is that the two 
hands of the auscultator are left free to prac- 



26 DISEASES OF THE HEART AND LUNGS. 

tise the method of auscultatory percussion. 
If the stethoscope be applied without press- 
ing upon the rubber bulb, it may be used in 
the same way as the ordinary instrument. 
The modified portion is made so that it can 
be screwed on or removed at pleasure from a 
stethoscope that has the usual movable chest- 
piece. 1 




Figure 7. 
Alison's differential stethoscope. 

The differential stethoscope of Scott Alison 
is similar in mechanism to Cammann's, but has 
two chest-pieces — one for each ear, enabling 
the sounds from different regions of the chest 
to be conveyed to the two ears at the same 
time. The value of this stethoscope has been 

1 N. Y. Med. your., Jan. 3, 1885. An instrument similar in 
principle is figured by Constantin Paul in his book on " Diseases of 
the Heart." 



1 



A USCUL TA TION. 2 7 

a matter of considerable controversy. It is 
claimed to be capable of offering aid to diag- 
nosis in two ways : (i) by the consecutive 
observation of the sounds of two regions of 
the chest by the different ears, and (2) by 
their simultaneous observation. We can listen 
over different parts of the chest with either 
ear by removing one or the other chest-piece, 
and thus can compare the sounds heard over 
different regions with great rapidity, and de- 
tect slight differences which might escape us 
in a prolonged examination. If we listen at 
two points simultaneously, and sound of the 
same quality but of different intensity is heard 
at each point, the weaker is eclipsed or nulli- 
fied, and thus, by the eclipsing of a weaker 
impression through one ear by a stronger im- 
pression through the other, differences may be 
recognized which might otherwise escape de- 
tection. When hearing is impaired in one ear, 
this stethoscope cannot be used satisfactorily. 
I have not found it of much practical value. 

The hydrophone is another instrument de- 
vised by Alison. It consists of an india-rubber 
bag about the size of a large watch, and filled 



28 DISEASES OF THE HEART AND LUNGS. 



with water. The hydrophone may be employed 
as an instrument by itself 
or in aid of the stetho- 
scope. The increase of 
sound varies much with the 
material through which it 
is conducted. With firm, 
non-flexible, or solid steth- 
oscopes, the hydrophone 
acts as a damper and dim- 
inishes sound. The more 
a stethoscope becomes a 
mere air instrument and 
departs from the character 
of a solid conducting me- 
dium, the more water adds 
to its acoustic value. This 
may explain why such op- 
posite results have been 
obtained in the use of the 
hydrophone by different 
observers. 

The author has devised 
an instrument for ausculta- 
tory percussion. It is sim- 
ilar to the binaural stetho- 




CAMMANN S BINAURAL HY 
DROPHONE FOR AUSCUL- 
TATORY PERCUSSION. 



A USCUL TA TION. 29 

scope, but closed at both ends and filled with 
water, thus carrying out the principle of Ali- 
son's hydrophone in another form. The two 
tubes leading from the ears to the flexible 
portion of the stethoscope are of hard rub- 
ber. The chest-piece is similar to that al- 
ready described. The central circular open- 
ing, the termination of the tube leading 
from the ears, is closed by a soft-rubber dia- 
phragm. The ear-pieces are hollow, very thin, 



Figure 9. 
cammann's intracostal solid cedar stethoscope. 

and made of hard rubber. In the chest-piece 
of the binaural hydrophone is a small metal 
tube which opens internally into the central 
tube of the chest-piece about a quarter of an 
inch above the rubber diaphragm. This is 
closed by a stopcock. The instrument is 
filled by placing the stopcock under a faucet, 
or attaching a rubber tube and pouring in the 
water, the rubber caps at the other end being 
partially unscrewed and allowing the enclosed 



3<3 DISEASES OF THE HEART AND LUNGS. 

air to escape through perforations in the 
screws. No bubbles of air should be allowed 
to remain. With a little care and proper 
manipulation it can be easily filled. 

Value of the Stethoscope. 1 — In considering 
the value of the stethoscope, it is taken for 
granted that the instrument used is reliable, 
and that the auscultator knows how to use it. 
Some skilful auscultators advocate its continual 
use ; others equally skilful advise that it be 
used only occasionally. The cause of this dif- 
ference of opinion probably lies partly in dif- 
ference in the acuteness of hearing and the 
extent of the training of different observers, 
and partly is a matter of habit. That the 
habitual use of the stethoscope does after a 
time render the sense of hearing less acute to 
the sounds heard over the chest in immediate 
auscultation is, I think, an undoubted fact. 
Yet the stethoscope is a valuable instrument, 
and although not always needed, often we 
cannot attain to a full knowledge of a case 
without making use both of mediate and im- 

1 " Handbook of the Medical Sciences," Wm. Wood & Co.; 
article " Stethoscope," by the author. 



A USCUL ta tion: 3 1 

mediate auscultation. Often a doubtful or 
half-heard sound has been clearly brought out 
and appreciated by the use of the stethoscope ; 
but still oftener, I think, has a sound scarcely 
suspected with the stethoscope been made 
evident by the immediate application of the 
ear. It requires some practice to become 
accustomed to its use, especially to that of the 
binaural instrument. In the latter some sounds 
are exaggerated, while others are impaired, 
and the distinctness and simplicity are lacking 
that are attained by the use of the ear or the 
monaural instrument. It is an acoustic fact 
that sounds are better heard with two ears 
than with one, and virtually the double stetho- 
scope enables us to place two ears on the chest 
at the same time. 

The value of the stethoscope for purposes 
of modesty, cleanliness, and convenience, and 
for examining the supraclavicular and axillary 
regions, which cannot readily be reached by 
the ear, is obvious, and needs only to be men- 
tioned to be appreciated. 

Value of a Knowledge of Acotistics. — The 
student will find that if he be familiar with 



32 DISEASES OF THE HEART AND LUNGS. 

the science of acoustics he will obtain a firmer 
grasp of his subject, and be assisted consider- 
ably in studying the sounds heard over the 
chest. Although the subject cannot be con- 
sidered at any length in this place, it may be 
permitted to recall some of the laws which 
will assist us in analyzing and comparing the 
sounds we are considering. 

In analyzing sounds we recognize the 
acoustic elements termed quality, intensity, 
pitch, and duration. These elements are to 
be considered in sounds heard on percussion 
and on auscultation. In the latter a fifth 
element is to be added, rhythm, which refers 
to the recurrence of sounds, whether they are 
regular or irregular. 

The Quality of a sound is that by which it 
is distinguished from all other sounds, and is 
due to the different intensities of the harmo- 
nies or secondary tones which accompany the 
fundamental note of a vibrating body. A 
note sounded on two bodies may be the same 
in intensity, pitch, and duration, but the 
quality will be different. 

The Intensity or loudness of sound is in flu- 



A USCUL TA TION. 3 3 

enced by the following causes : (i) The 
amplitude of the vibrations. (2) The dis- 
tance of the sonorous body from the ear ; e. g, 
a cavity separated from the periphery by 
healthy lung may be appreciated with diffi- 
culty. (3) The density of the medium 
through which the sound is conveyed ; e. g, 
consolidated lung readily conveys bronchial 
sounds, and a cavity surrounded with consoli- 
dated lung is readily appreciated. On the 
other hand the consolidation of centric pneu- 
monia, removed from the periphery by healthy 
lung, may not be readily recognized. (4) The 
direction of the currents of air or fluid ; e. g., 
in health the bronchial element of the respira- 
tion is heard in inspiration, and not in expira- 
tion, because in inspiration the current of air 
is carried along the larger bronchi towards 
the ear, and the bronchial sounds naturally 
follow the same direction, but in expiration 
the reverse is the case. In mitral regurgita- 
tion the sound of the column of back-rushing 
blood is projected directly into the ear to the 
left of the seventh dorsal vertebra. (5) The 
proximity of other sonorous bodies ; e. g, 



34 DISEASES OF THE HEART AND LUNGS. 

rales are intensified by the proximity of a 
cavity. The sternum, acting' as a sounding- 
board, may convey heart murmurs to a con- 
siderable distance. The heart-sounds near 
the apex are tympanitic in quality if the 
stomach be distended with gas and fluid. 

Pitch means the same as the term does 
in music. The pitch depends upon the 
number of vibrations in a given time. The 
pitch of the percussion note over the small 
intestine is higher than over the stomach, 
because a cavity containing a small amount 
of air gives a greater number of vibrations 
a second than a cavity containing a large 
amount. If the cavity be distended and 
the compression of the contained air in- 
creased, the percussion note will be raised 
in pitch, because with increased compres- 
sion the number of vibrations is increased. 
So at the end of inspiration the percussion 
note over the lungs is higher than at the end 
of expiration, because, although the amount 
of air in the lungs is greater, the compression 
of the air and the tension of the lung tissue 
is at the same time increased. 



A USCUL TA TION. 55 

Some of the causes upon which depends 
the pitch of the sounds produced by air pass- 
ing through the bronchi are, the calibre of the 
tube, its smoothness or roughness, the velocity 
of the air current, and the condition of the 
surrounding tissues. 

Consonance. — Consonance is from the Latin 
consono, I sound together. When a musical 
note is sounded upon the strings of a guitar, 
a second guitar near-by will produce a note of 
the same pitch, the one reinforcing the other. 
This is known in music as consonance, and 
is true of all sounding bodies in the neigh- 
borhood of other sounding bodies producing 
a note of the same pitch. Thus the voice is 
reinforced by sounding bodies responding to 
its vibrations, as, for example, in issuing from 
the mouth it is increased in volume and force 
by throwing the air in the adjacent cavities 
into simultaneous vibration. Skoda attri- 
butes bronchial breathing and bronchophony 
heard over consolidated lung to consonance 
due to the altered condition of the bronchi. 
This theory is rejected by most authorities, 
who attribute the phenomena to the better 



$6 DISEASES OF THE HEART AND LUNGS. 

conduction of sound by the increased density 
of the lung. With our present knowledge it 
is difficult to say how far consonance assists 
in the reinforcement of thoracic sounds, but 
neighboring parts undoubtedly modify them, 
and the liver, stomach, and intestines have 
such an influence. 

Unison Resonance. — By unison resonance is 
meant the reinforcement which occurs in the 
box of a guitar when notes are produced by 
its strings, or when a tuning-fork is held 
upon a table instead of in the air. There 
can be little doubt that in the same way the 
thoracic walls assist in the reinforcement of 
sound. 

Echo. — By echo is meant the repetition of 
sounds. It is a probable cause of their reinforce- 
ment. Existing theories fail to explain some of 
the phenomena of echoes, and we scarcely yet 
understand the laws by which they are gov- 
erned. In some cases of posterior consoli- 
dation in one lung, bronchial breathing and 
bronchophony have been heard at a distant 
point over the other lung. This has been ex- 
plained by the laws of echo. 



RESPIRATION IN HEALTH. 37 

RESPIRATION IN HEALTH. 

In the respiration in health, inspiration is 
three or four times longer than expiration. 
Expiration as heard over the chest of old per- 
sons is usually considerably longer than this. 

Inspiration is of considerable duration and 
intensity, of low pitch and pulmonary quality. 
It is of a soft, breezy character, neither liquid 
nor dry, increasing in intensity at first, but 
again decreasing before the end of the inspira- 
tory act. Expiration is harsher and lower- 
pitched, and of considerably less intensity. 
It is heard at the beginning of the expiratory 
act, but is lost before it is one third or at 
most one half over. In about one in four of 
healthy persons expiration is not heard at all. 

We recognize that the sound produced in 
respiration is not a single element, but is com- 
posite, and in certain regions of the chest or 
under certain conditions one or the other 
element may predominate. Considerable dif- 
ference of opinion still exists as to the causes 
that produce the respiratory murmur. The 
controversy cannot be entered into here, but 



38 DISEASES OF THE HEART AND LUNGS. 

the question will be considered from a purely- 
clinical standpoint. The two elements of 
which the respiratory murmur is composed 
are the bronchial, caused by air friction in the 
larger bronchial tubes, and the vesicular ele- 
ment, produced in the lung proper. 1 Various 
and conflicting theories have been advanced 
as to the cause of the vesicular murmur, but 
in the present state of our knowledge of 
thoracic physics none of the views that have 
been advanced are capable of demonstration 
(Walshe). The bronchial element, which is 
heard with greatest intensity in inspiration 
and feebly or not at all in expiration, is some- 
what high-pitched and harsh. It is most 
marked in children and is then called "puerile 
breathing." It may be increased in the adult 
by forced respiration. In the adult it is 
specially noticeable under the right clavicle 
and in the interscapular regions. The vesicu- 
lar murmur is soft, low-pitched, of little in- 
tensity, and heard both in inspiration and 

1 Learning believes the respiratory murmur to be composed of two 
murmurs, which he calls the true respiratory and the broncho-respira- 
tory, and that each may be isolated. — " Diseases of the Chest," New 
York, 1887. 



RESPIRATION IN HEALTH. 39 

expiration, increasing in the one and decreas- 
ing in the other. It is absent in young 
children and is not fully developed until 
maturity. A' change in the form of the chest 
or a thick layer of muscles or fat may render 
this murmur difficult of recognition. 

Vocal Resonance. — If the ear be placed upon 
a healthy chest while the person speaks, the 
vibrations of the voice are heard without dis- 
tinct phonation as a buzzing, vague, and 
distant sound. Its quality will vary with the 
person's voice. It is low-pitched and most 
intense in those having a deep, low-pitched 
voice. The phonation, however, is more 
distinct when the voice is high-pitched. Over 
the larger bronchi at the upper part of the 
sternum in front and in the interscapular 
regions behind, the vocal resonance is more 
concentrated and intense than over the re- 
mainder of the chest. Its intensity is usually 
greater over the right lung than over the left. 
If the person be made to whisper, the sound 
is conveyed to the ear as a slight and distant 
puff or merely as an exaggeration of the ex- 
piratory sound. Coughing produces a sharp, 



40 DISEASES OF THE HEART AND LUNGS. 

quick sound which jars the whole chest. What 
we learn by auscultation of the voice is chiefly 
of value to confirm knowledge acquired by 
other means. 

Vocal Fremitus is the vibrations of the voice 
felt through the chest walls. Vibrations of a 
coarser and more violent character are needed 
for its production than for the production of 
vocal resonance. 1 

1 The former is supposed to depend upon the vibrations transmitted 
through solid tissues, the latter mainly upon the column of air in the 
trachea and bronchial tubes vibrating after the fashion of an organ- 
pipe. — Stone : " Cromian Lectures," Lancet, Aug. 9, 1879. 



SECTION II. 

PERCUSSION IN DISEASE. 

The general remarks already made in regard 
to percussion apply equally to percussion in 
health and in disease. Whatever be the nature 
of the disease, its area will either be sharply 
defined or not. In the former case little diffi- 
culty will be experienced in mapping out its 
limits. In the latter we may be in some doubt, 
and it will assist us to rapidly percuss over the 
suspected area so as to compare the different 
parts as quickly as possible. A change in the 
density of the lung, in the amount of air 
present, in the thickness of the pleura, or the 
presence of fluid, will cause a change in the 
percussion note, and we may estimate the 
extent of these changes not only by the sound 
elicited, but by the feeling of resistance expe- 
rienced by the fingers. 



42 DISEASES OF THE HEART AND LUNGS. 

We may obtain exaggerated pulmonary res- 
onance, dulness, flatness, amphoric resonance, 
tympanitic resonance, and cracked-pot reso- 
nance. 

Exaggerated Pulmonary Resonance. — The 
pitch is lower and the intensity and duration 
greater than in normal pulmonary resonance. 
It is heard over a lung doing extra work, 
in emphysema, and in cases of marked 
anaemia. 

Dulness may be increased where it is nor- 
mally present, or present in abnormal situa- 
tions. It indicates a decrease in the amount 
of air, or interference with the normal vibra- 
tions of the lung tissue. Dulness varies within 
pretty wide limits : it may be slight, and only 
a little higher pitched than pulmonary reso- 
nance ; or, on the other hand, well marked, and 
only a little lower in pitch than flatness. It is 
heard over consolidated lung, fluid in the 
pleural cavity, thickened pleura, emphysema, 
aneurism, hypertrophy of the heart. 

Flatness. — It indicates a solid body of con- 
siderable size. It is heard over large pleuritic 
effusion, pleura very much thickened, consoli- 



PERCUSSION IN DISEASE. 43 

dated lung when pressed firmly to the chest 
wall, tumors, aneurisms. 

Tympanitic Resonance is heard over cavities 
and in pneumothorax. It may be transmitted 
through consolidated or compressed lung from 
the stomach or intestines. The resonance re- 
sembling tympanitic, heard over lung partially 
collapsed and containing fluid, has a pulmo- 
nary character, is less metallic than, and can 
be distinguished from, tympanitic resonance. 

Amphoric Resonance is heard over large cav- 
ities. The greater the compression of the air 
and tension of the walls in the cavity, the 
higher the pitch. 

Cracked-pot Sound. — The quality is metallic, 
and the pitch varies with the size of the cavity. 
It is heard over cavities communicating with a 
bronchial tube by a small opening, and resem- 
bles the sound produced by striking the hands 
loosely clasped against the knees. It is heard 
best when the patient's mouth is open. Some- 
times it is observed in healthy children whose 
chest walls are thin and elastic. 

Respiratory Percussion. — The percussion 
note varies at the end of a full inspiration and 



44 DISEASES OF THE HEART AND LUNGS. 

a prolonged expiration, and to this method of 
diagnosis Da Costa has given the name of res- 
piratory percussion. At the end of a full held 
inspiration in a normal chest the sound is in- 
creased in intensity and raised in pitch, while 
at the end of a forced expiration the reverse is 
the case. 

In emphysema the change in the percussion 
note between the extremes of respiration is 
scarcely appreciable. In the early stage of 
phthisis dulness is best detected by percussing 
the patient with his mouth open during a fixed 
expiration, and the difference between the two 
sides becomes manifest during a held inspira- 
tion. As the consolidation becomes greater 
dulness is little influenced by respiration, while 
over a cavity a tympanitic percussion note be- 
comes dull with a held inspiration. Over a 
compressed lung dulness becomes less with a 
held inspiration. 

AUSCULTATION IN DISEASE. 

In disease the respiratory sounds over the 
normal lung may be modified, or adventitious 
sounds may be heard. Sometimes a single 



AUSCULTATION IN DISEASE. 45 

physical sign will be pathognomonic, but in 
the great majority of cases it is only by group- 
ing together the various physical signs, and 
even drawing upon clinical histories and our 
pathological knowledge, that we are enabled to 
arrive at a correct diagnosis. 

Harsh Respiration is the bronchial element 
of the respiration of the healthy adult exagger- 
ated, and is produced in the normal chest by 
increasing the rapidity of the breathing. In 
children it is normally present and is then 
called puerile respiration. The vesicular ele- 
ment of the respiration may be unchanged or 
diminished. Harsh respiration may be heard 
in inspiration alone, or in inspiration and ex- 
piration, and in the latter case it may be of 
higher pitch and of greater intensity in one 
than in the other. Harsh respiration when it 
becomes marked approaches bronchial breath- 
ing in character, and there is no strict dividing 
line where the one ends and the other begins. 
Harsh respiration indicates slight condensa- 
tion or consolidation of the lung, dryness of 
the mucous membrane of the bronchi, plastic 
exudation into the pleura sufficient to slightly 



46 DISEASES OF THE HEART AND LUNGS. 

compress the lung beneath, and even consider- 
able consolidation if there be healthy lung be- 
tween it and the chest wall. 

Feeble Respiration. — The respiration is di- 
minished in intensity and perhaps in pitch. 
Either the bronchial or the vesicular element 
of the respiration may be suppressed, or one 
or both be faintly heard, k is observed over 
lung in which the expansion is diminished by 
pain, with obstructions in the larynx or trachea, 
over pleuritic adhesions binding the lung to 
the chest wall, and with paralysis of the dia- 
phragm or costal muscles. 

Suppressed Respiration. — It is observed 
when little or no air enters the lungs. No 
sound is heard, or at most only a slight sound 
at the end of inspiration. It is due to the 
same causes carried to extremes as feeble res- 
piration. 

Prolonged Expiration. — Expiration is longer 
than inspiration. Usually a change in quality 
and pitch accompanies the lengthened expira- 
tion. It is due to want of freedom of the 
passage of air from the lungs, from loss of re- 
siliency of lung tissue, or from some mechanical 



AUSCULTATION IN DISEASE. 47 

obstruction. When these two causes are com- 
bined, as in the loss of resiliency in emphy- 
sema, together with the mechanical obstruction 
of inspissated mucus from bronchitis, we have 
the greatest prolongation. 

Cogged-wheel Respiration. — The respiration 
is interrupted or jerking in character and may 
occur both with inspiration and expiration. 
Sometimes it is not heard throughout the 
whole of the inspiration but during the first or 
last part. It may be heard over both lungs or 
over a part of one lung, and is supposed to be 
due to mucus adhering to the walls of the 
swollen bronchi, causing obstruction to the 
free passage of air. In some cases it is a 
purely nervous phenomenon, unconnected 
with any disease of the lungs. In cases where 
the interruptions were synchronous with the 
movements of the heart, they have evidently 
been due to pericordial adhesions. It has been 
observed in phthisis, incipient pleurisy, pleu- 
rodynia, hysteria, intercostal neuralgia. 

Bronchial Respiration. — The pitch is high. 
Expiration is as long or longer and higher 
pitched than inspiration. The quality is bron- 



48 DISEASES OF THE HEART AND LUNGS. 

chial. It is the natural bronchial breathing 
which, owing to morbid conditions, is readily 
conveyed to the ear. Sometimes it is diffused, 
of no great intensity, and distant from the ear ; 
at others intense, metallic in character, and di- 
rectly under the ear. It is heard over con- 
solidated and compressed lung, excessively 
thickened pleura, dilated bronchi, and cavities. 

Cavernous Respiration is hollow and blowing 
in character and low-pitched. Expiration is 
almost invariably lower pitched than inspira- 
tion. It is heard over cavities and largely 
dilated bronchi. The cavity must contain 
little or no fluid, be near the surface, have 
free communication with a bronchus, and have 
flaccid walls. 

Amphoric Respiration is a sound of a musi- 
cal character, like that produced by blowing 
into an empty bottle. It may be humming 
and low-pitched, or metallic and high-pitched, 
the pitch varying with the size of the cavity. 
It is heard over cavities. Typical amphoric 
respiration is heard over large cavities with 
tense walls. 

Metallic Tinkling is a short, clear, high- 



A USCUL TA TION IN DISRA SE. 49 

pitched, metallic sound resembling that pro- 
duced by letting drops of water slowly fall 
into a decanter partially filled with fluid, or 
by breathing into the water through an elas- 
tic tube. It is usually heard towards the end 
of inspiration, but rarely with any considera- 
ble number of consecutive respirations. A 
uniform conclusion as to the cause of metallic 
tinkle has not been reached. It is probably 
produced in cavities containing fluid, either 
by drops of fluid falling from the roof, or by 
bubbles of air passing through the fluid, or 
rales generated in communicating bronchial 
tubes may be echoed with metallic tinkle. It 
is most often produced by coughing or speak- 
ing, and is heard over large cavities and in 
hydropneumothorax. 

The peculiar and rare form of breathing, 
known as Cheyne-Stokes respiration, occurs in 
many different diseases, but most frequently 
in those of the brain and heart. It indicates 
a depressed condition of the nervous system, 
and is usually followed by a fatal result. It 
consists in a pause, during which respiration 
entirely ceases ; this is followed by respira- 



50 DISEASES OF THE HEART AND LUNGS. 

tions which at first short and shallow become 
gradually deeper, and then again shorter and 
shallower until they come to a standstill. In 
well-marked cases this whole cycle of changes 
takes from one to one and a half minutes. 

The Voice in Disease. — The knowledge ac- 
quired by vocal resonance in disease is not 
of much importance, although occasionally 
useful in confirming conclusions reached by 
other means. 

Exaggerated Vocal Resonance. — The inten- 
sity of normal resonance is increased without 
any change in quality. It is heard over lung 
slightly consolidated or compressed, or over 
lung bound to the chest wall by pleuritic ad- 
hesions. 

Diminished Vocal Resonance is caused by 
some interference with the conveyance of 
sound, either by obstruction in the bronchi or 
removal of the lung from the chest wall. It 
occurs in pleuritic effusions, pneumothorax, 
emphysema. 

Suppressed Vocal Resonance is observed over 
large pleuritic effusions, in pneumothorax and 
emphysema. 



AUSCULTATION IN DISEASE. 5 1 

Bronchophony. — It is high-pitched and of 
variable intensity, almost metallic in quality, 
concentrated, and near the ear. The articula- 
tion of the words is not appreciated. It occurs 
over consolidated lung, cavities, or dilated 
bronchi. 

Aigophony is a variety of bronchophony 
peculiarly tremulous, cracked, ringing, and 
muffled in character, and has been compared 
to the bleating of a kid. It is of short dura- 
tion, usually persistent, although it does not 
accompany every spoken word even of the 
same pitch. It is appreciated best in patients 
with a vibrating voice, and most commonly 
heard behind, nearly on a level with the 
angles of the scapulae. It is observed in some 
cases of pleurisy with effusion at or a little 
below the level of the fluid, but not usually 
with a large accumulation of fluid. When 
loose cellular adhesions hold the lung to the 
chest and the layer of fluid between is thin it 
is sometimes heard quite extensively. 

Pectoriloquy is an exaggerated bronchophony 
in which not only the sound of the voice but 
the articulation of the words is conveyed 



52 DISEASES OF THE HEART AND LUNGS. 

through the chest wall. It occurs over cavi- 
ties or consolidated lung. When heard over 
a cavity, the cavity is probably of moderate 
size, empty, with firm walls, near the surface, 
attached to the chest walls by adhesions, and 
freely communicating with a bronchus. 
Heard over consolidation, it is evidence that 
the consolidation lies between the chest wall 
and a main bronchus. 

Amphoric Voice has the same quality and 
meaning as amphoric respiration. 

Whispering is heard but faintly over a 
healthy chest. In disease it is absent if the 
transmission of sound be interfered with, as in 
emphysema and in pleurisy with effusion, or it 
may be heard distinctly in conditions favoring 
the transmission of sound, as in consolidation, 
in enlarged bronchi, and over cavities, and we 
may have whispering pectoriloquy. 

The resonance produced by cough is dimin- 
ished or increased under conditions interfering 
with or favoring the transmission of sound. 
By auscultating at the time of the cough and 
during the deep inspiration that the patient 
naturally takes afterwards, physical signs are 



RALES. 53 

often discovered that might otherwise escape 
notice. 

Vocal Fremitus may be increased or dimin- 
ished, and does not always correspond with 
the increase or diminution of the voice. It 
may be increased by pulmonary consolidation 
or pleuritic adhesions, and is diminished by 
fluid or air in the pleura. If the consolidation 
be considerable and little air be admitted into 
the lung, vocal fremitus is not felt. 

RALES. 

The respiratory sounds hitherto considered 
have been morbid changes of normal breath 
and voice sounds. Rales are certain adven- 
titious sounds produced within the chest, never 
present in health, and heard with respiration or 
the movements of the heart. 

Rales are crepitant, subcrepitant, coarse, 
gurgling, sibilant, and sonorous. 

Pleuritic friction may also be considered in 
this connection. 

Crepitant Rales are fine, sharp, dry crackles 
all of the same size, usually heard with inspira- 
tion, and resemble the sound produced by a lock 



54 DISEASES OF THE HEART AND LUNGS. 

of hair forcibly rubbed between the thumb and 
forefinger, or by salt when thrown on the fire. 

Subcrepitant Rales are moderate and un- 
equal sized, moist or dry, rather quick crackles. 

Coarse Rales are moist or dry, bubbling, of 
unequal size, and larger than subcrepitant 
rales. Sometimes a single sharp, high-pitched 
metallic click is heard with the respiration or 
the movements of the heart. 

Gurgling Rales are large, moist, unequal- 
sized bubbles, sometimes metallic in character. 
The death rattle is an example of this rale. 

Sibilant Rales are whistling or hissing in 
character, dry, high-pitched, and varying con- 
siderably in intensity and duration. 

Sonorous Rales are snoring in character, dry, 
low-pitched, varying much in intensity and 
duration. 

Sibilant and sonorous rales are produced 
within the bronchi, the sonorous usually in the 
larger and the sibilant in the smaller. The 
others, crepitant, subcrepitant, coarse, and gur- 
gling rales, may be of intrapulmonary or intra- 
pleural origin. 

The time is not long past when all rales 



RALES. 55 

were supposed to be of intrapulmonary origin, 
but the labors of Learning in this country and 
of Walshe and Sir Andrew Clark in England, 
have demonstrated beyond doubt that rales 
are produced within the pleurae, and have even 
led us to doubt if crepitant and subcrepitant 
rales are ever of intrapulmonary origin. 

Besides sounds that are produced either 
within the lung or pleura? there are others — 
friction sounds, which have their origin in the 
pleurae, and have the quality of grazing, rub- 
bing oratina-, creaking, or rumbling, most in- 
tense in inspiration, single, continuous, or 
divided and jerking, lasting for a considerable 
time, or chano-ino- from hour to hour. The 
grazing is only heard at the commencement of 
pleurisy when the membrane becomes dry. 
Later, when the epithelium has fallen off and 
the surface becomes roughened, rubbing or 
grating sounds are heard, and may occur not 
only early but after the morbid condition has 
continued for some time. Usually not before 
the disease has become chronic, are creaking, 
rumbling sounds heard. The creaking re- 
sembles that produced by new leather, and 



56 DISEASES OF THE HEART AND LUNGS. 

may also originate within the lung from the 
wall of a chronically thickened bronchus or a 
cavity in the lung tissue. We can judge some- 
what of the age of the adhesions by the char- 
acter of the rales. With a slight exudation of 
delicate plastic material we may only obtain a 
few fine rales which are heard with difficulty, 
or with an abundance of exudation we have a 
shower of crepitant rales. When the adhesions 
are not so delicate we have subcrepitant rales. 
When the adhesions are old and firm we may 
obtain dry, coarse rales, and the creaking 
already described. With meshes of plastic 
matter infiltrated with serum we have moist, 
coarse, and gurgling rales. When these rales 
are produced in the pleura immediately over a 
cavity in the proper acoustic condition, they 
may become metallic in quality and increased 
in intensity by the cavity acting as a resonator. 
Rales due to adhesions between the surfaces 
of the pleura are most apt to occur at the end 
of inspiration ; when due to plastic exudation, 
they are most often heard towards the middle 
or end of inspiration, but may also occur with 
expiration. 



RALES. 57 

Adventitious Sounds in the Chest Wall. — 
The muscular action going on in the chest 
wall gives rise in some persons to a peculiar 
buzzing- sound called muscular sussurus. Its 

o 

amount does not seem to depend upon the 
muscularity of the individual. It is increased 
by exertion, is continuous, and seems rather 
augmented in intensity when the breath is 
held. It may be removed over most parts of 
the chest by relaxing the muscles. 

Rales are sometimes produced by pressing 
the stethoscope against hair on the surface, or 
by emphysematous or cedematous subcutane- 
ous tissue, or we may be deceived by the 
crepitus of a fractured rib. The sounds pro- 
duced by the swallowing of saliva, by intestinal 
borborygmi, or the metallic tinkling sometimes 
heard over a stomach containing gas and fluid, 
and transmitted to the ear through the lungs, 
will, with a little care, be readily traced to 
their proper source. 

Facts and Theories in Regard to the Origin 
of Rales. — A lengthy consideration of the 
origin of rales would be out of place in this 
work, but on account of its interest and im- 



58 DISEASES OF THE HEART AND LUNGS. 

portance the subject may be briefly con- 
sidered. 

It is difficult to draw a sharply defined line 
between facts and theories. We may draw 
logical conclusions from a group of facts which 
will be accepted by every candid mind ; we 
may, on the other hand, draw conclusions 
which are nothing more than the wildest 
theories. We cannot listen to rales and then 
view the site of their production, and even in 
those cases where we obtain a post-mortem 
examination a short time after auscultation 
our observations may seem equally to support 
conflicting views. Sibilant and sonorous rales, 
it is generally .conceded, are produced by 
diminution in the calibre of the larger bronchi, 
either by the presence of viscid mucus or some 
other obstruction. Coarse or mucous rales and 
gurgling rales, it is also conceded, are pro- 
duced' in the larger bronchi by the passage of 
air through a more or less fluid secretion, but 
it is also claimed that rales identical in charac- 
ter are of intrapleural origin. Crepitant and 
subcrepitant rales were generally supposed to 
be produced within the lung, but it is now be- 



RALES. 59 

lieved by many of the best auscultators that 
rales similar, if not identical, in character are 
of intrapleural origin, and some believe that 
they are always so. 

Reasoning from analogy, the subcrepitant 
rales are believed to have their origin in the 
smaller bronchi in the same way that coarse 
rales are produced in the larger, by the passage 
of air through secretion, and experimenters 
have demonstrated that by injecting liquids 
into the bronchi, rales are produced. Still 
reasoning from analogy, it is believed that 
crepitant rales, being smaller than coarse or 
subcrepitant rales, are produced by the pas- 
sage of air through exudation in the air-cells, 
and also probably in the terminal bronchi. 
Some authors claim that the exudation must 
be aqueous or serous, and that a mucilaginous 
mixture will not produce the rales ; others say 
that they are only produced by a mucilaginous 
exudation, and both sides bring forward ex- 
periments and arguments in support of their 
views. Another view is that the air-cells 
collapse during expiration, and during inspira- 
tion the sudden separation of their aggluti- 



6o DISEASES OF THE HEART AND LUNGS. 

nated walls produces rales, and it is argued that 
a similar sound is produced by pulling apart 
two fingers previously gummed together by 
their palmar surfaces, by applying the tongue 
to and gradually detaching it from the roof of 
the mouth, or by inflating the collapsed lungs 
in the dead body, the walls of the alveoli be- 
ing in contact after death. 1 A third view is 
that the rales are produced in the parenchyma 
of the lung itself by the sudden and forcible 
expansion of the pulmonary tissue glued to- 
gether by the viscid exudation with which it 
is infiltrated.' In support of this latter view 
are urged the usual dryness and sharpness of 
the sound, its resemblance to the minute rup- 
ture of tissues, and the absence of bubbling 
character ; its occasional presence throughout 
inspiration, and sometimes only at its close, 
according as infiltration of the viscid exuda- 
tion more or less prevents expansion of the 
vesicles. We can readily understand, too, why 
this rale should usually occur in inspiration, as 
the rapid expansion would be more apt to 

1 Guttmann : " Physical Diagnosis," New York, 1880. 

2 " Diseases of the Lungs," Walshe, 4th edition. 



RALES. .6 1 

produce it than the comparatively slow and 
passive contraction. A fourth view is that 
both subcrepitant and crepitant rales are pro- 
duced within the pleura, and that coarse and 
gurgling rales are produced both in the bron- 
chi and in the pleura. 

Many of the arguments urged in favor of 
the production of rales in the parenchyma of 
the lung apply equally to their origin within 
the pleura. The stretching of pleuritic adhe- 
sions or the friction of two plastic surfaces 
might readily produce the same sounds as the 
expansion of lung tissue infiltrated with exu- 
dation ; and we can easily understand why the 
rales would more commonly occur in inspira- 
tion when the adhesions would be put on the 
stretch or when the plastic material would be 
subjected to the most pressure ; in fact, all the 
conditions for producing rales are more favor- 
able in the pleura than in the lung tissue. 

Many cases are on record in which rales, 
crepitant, subcrepitant, coarse, and gurgling, 
were heard a short time before death, and on 
post-mortem examination pleuritic exudation 
was found in the same situation, while the 



62 DISEASES OF THE HEART AND LUNGS. 

lung beneath, in some cases, was not diseased, 
and in others was consolidated, so that no air 
could have entered the lung in the neighbor- 
hood where the rales were heard. 1 Carefully 
recorded cases do not disprove this view. The 
cases recorded by Laennec 2 and by Louis 3 
show that crepitant and subcrepitant rales 
were only heard over the site of pleuritic 
adhesions. 

In opposition to the view that crepitant and 
subcrepitant rales are produced in the smaller 
bronchi and the air-vesicles, it may be urged 
that it would be necessary for the respiration 
to have considerable force in these situations, 
or at least that a current of air must pass in 
and out with each respiration, But physiology 
teaches that this does not occur. The change 
that takes place in the air in the air-cells and 
smaller bronchi is not by currents of foul air 
passing out in expiration and currents of fresh 

1 " Primitive Dry Pleurisies," Sir Andrew Clark, Lci7icel, April n, 
1885. " Diseases of the Chest," Learning, N. Y., 1887. " Diseases 
of the Lungs," Walshe, 4th ed., p. 120. " Pathological Anatomy," 
Delafield, p. 31. 

' 2 Laennec on " The Chest." 

3 Louis on " Phthisis." 



RALES. 63 

air passing in with inspiration, but the change 
is governed by the well-known law of the dif- 
fusion of gases. 

" By diffusion," says Foster, 1 " the new or 
tidal air gives up its oxygen to and takes car- 
bonic acid from the old or stationary air. In 
this way, by the ebb and flow of the tidal air, 
and by diffusion between it and the stationary 
air, the air in the lungs is being constantly 
renewed." 

That such is the case is evident from the 
fact that only about one tenth of the air in the 
lungs is changed in each respiration. When 
one lung is crippled by disease the other lung 
does extra work, as is evidenced by harsh 
respiratory murmur over the unaffected side, 
and the diseased lung receives less air than 
usual at each respiration. And yet it is over 
such a lung, receiving a small amount of air, 
and in which there can be little or no current 
in the smaller bronchi and air-vesicles, that 
crepitant and subcrepitant rales are often 
heard. That rales may arise from the sudden 
separation of the cohering walls of the air-cells 

1 Foster, "Physiology," London, 1887, p. 219. 



64 DISEASES OF THE HEART AND LUNGS. 

is contrary to the teachings of physiology. 
The air-cells do not collapse in expiration ; 
nine tenths of the air in the lungs at the end 
of inspiration remains at the end of expiration. 
That rales may arise in air-cells partially filled 
with exudation by the separation of their ad- 
hering sides seems more probable. But it 
must be remembered that little air enters the 
parts of the lung where the exudation has 
taken place ; there can be little or no current ; 
the lung is crippled, and expansion and con- 
traction take place to a very limited extent. 

If, however, the current of air were sufficient 
to produce these fine rales, there would be no 
reason why they should not be heard in expi- 
ration as well as in inspiration, as the air that 
would pass through the fluid in inspiration 
would have to pass through it again in expi- 
ration. Rales which we know are produced 
by air passing through fluid are heard both in 
inspiration and expiration. These fine rales, 
however, are rarely heard in expiration. The 
fact that similar rales may be produced by 
injecting liquids into the bronchi only proves 
that certain sounds may be generated under 



RALES. 65 

certain conditions, and is nothing more than 
presumptive evidence. Crepitant rales are 
produced by throwing salt into the fire, or by 
rolling a lock of hair between the fingers. 

The view that the seat of the finer rales is 
in the smaller bronchi and air-vesicles is open 
to grave objection ; that their seat is in the 
parenchyma of the lung or in the pleura is 
much more plausible, and the knowledge that 
we have lately gained of the physical signs of 
pleuritic exudation would seem to point to the 
pleura as the frequent if not the only seat of 
crepitant and subcrepitant rales, as well as a 
sharer with the bronchi in the production of 
coarse and gurgling rales. 



SECTION III. 

ACUTE BRONCHITIS. 

Percussion — N o r m al . 

Auscultation. — Owing to the limited area 
involved, or the large size of the tubes, bron- 
chitis may run its course without any physical 
signs. The only auscultatory sign may be a 
slight harshness of the bronchial element of 
the respiration, or it may be harsh, loud, and 
raised in pitch. With the dry stage sibilant 
and sonorous rales may be heard, and with the 
presence of secretion coarse and gurgling 
rales, the sibilant and sonorous rales either 
remaining or disappearing. The rales are 
distant from the ear, and disappear or change 
position on coughing. They may be few or 
so abundant as to mask the respiration. 

CHRONIC BRONCHITIS. 

The conditions usually described under this 
title vary from simple bronchitic lesions to 

66 



CAPILLARY BRONCHITIS. 67 

those in which the peribronchial and pul- 
monary tissues are involved, or the bronchi 
themselves dilated (bronchiectasis). 

Percussion. — Percussion is normal, or if the 
peribronchial tissue is sufficiently implicated 
the pitch is raised. A dilated bronchus gives 
the same percussion note as a phthisical cavity. 

Auscultation. — We have the same signs as 
in acute bronchitis, namely, harsh respiration, 
sometimes approaching bronchial ; sibilant, 
sonorous, coarse, and gurgling rales, the rales 
being few or abundant, more or less distant 
from the ear, and changing position on cough- 
ing. The respiration may be feeble, and creak- 
ing, leathery sounds may be heard from the 
thickened bronchi. A dilated bronchus gives 
the physical signs of a cavity, and the differ- 
ential diagnosis from a phthisical cavity is 
rarely possible from the physical signs alone. 

CAPILLARY BRONCHITIS. 

Percussion. — N o rmal. 

Auscultation. — Subcrepitant rales on in- 
spiration and expiration. 

If the views in regard to the intrapleural 



68 DISEASES OF THE HEART AND LUNGS. 

origin of rales discussed in an earlier part of 
this work are accepted, then the subcrepitant 
rale can no longer be considered a sign of 
capillary bronchitis, but of the presence of 
pleuritic exudation. 

LOBAR PNEUMONIA. 
First Stage or Stage of Engorgement. 

Inspection. — Movement on the affected side 
is diminished. At first the sputa are frothy 
mucus, which floats on the surface of water. 
Later it becomes viscid and so tenacious that 
it adheres to the bottom of the vessel contain- 
ing it. The sputa may be tinged with blood 
and be brick-dust color or very dark and prune- 
juice color. The sputum is often character- 
istic. 

Percussion. — The percussion note is raised 
in pitch, the variation in the pitch depending 
upon the extent of lung involved and its dis- 
tance from the periphery. 

Auscultation. — The vesicular element of the 
respiration is muffled ; the bronchial element 
slightly exaggerated. Crepitant rales are often 



LOBAR PNEUMONIA. 69 

heard with inspiration in this stage. They 
are signs of pleuritic exudation. 

Second Stage or Stage of Consolidation. 

Inspection. — Expansion diminished on the 
affected side. 

Palpation. — Vocal fremitus increased or 
occasionally, with extensive consolidation, 
diminished. 

Percussion. — Dulness more or less marked, 
according- to the extent of lung involved and 
its nearness to the periphery. If the consoli- 
dation be distant from the surface, with healthy 
lung tissue lying between, little or no dulness 
is perceptible. 

Auscultation. — Bronchial breathing and 
bronchophony. The more complete the con- 
solidation, the more marked are the physical 
signs. The heart sounds are also conveyed 
with increased intensity. If the consolidation 
is separated from the chest wall by healthy 
lung tissue and the area of consolidation is 
small, bronchial breathing and bronchophony 
may not be heard, but the vesicular element 
of the respiration will be feeble. 



70 DISEASES OF THE HEART AND LUNGS. 

Third Stage or Stage of Resolution. 

At first the signs are the same as in the 
preceding stage. 

Percussion. — Dulness, gradually decreasing. 
A considerable time often elapses before the 
percussion note becomes normal, especially 
with extensive pleuritic exudation. 

Auscultation. — A gradual change takes place 
from bronchial to harsh, and finally to nor- 
mal respiration and bronchophony disappears. 
The Crepitant rale or the " rale redux " is often 
heard in this stage. It is a sign of pleurisy. 
Coarse rales are more or less abundant. 

LOBULAR PNEUMONIA. 

The consolidation of lobular pneumonia if 
extensive enough produces the same physical 
signs as lobar pneumonia — namely, dulness on 
percussion, and on auscultation harsh or bron- 
chial respiration, with increased vocal reso- 
nance or bronchophony and increased vocal 
fremitus. The pneumonia is usually accom- 
panied by bronchitis with both fine and coarse 
rales. The areas of consolidation may be so 
small and disseminated as to give no appre- 



PLEURISY. yi 

ciable physical signs. If there is accompany- 
ing emphysema, increased pulmonary reso- 
nance may be present over the upper part 
of the chest. 

PLEURISY. 
Pleurisy with the Exudation of Fibrin. 

Inspection. — Early in the disease, with dry- 
ness of the pleural surface, inspection shows 
a diminution in the respiratory movements, 
especially over the affected side, and with the 
appearance of plastic exudation the diminution 
is more marked. 

Percussion. — Pulmonary resonance or dul- 
ness. When the exudation is thin the pitch 
of the percussion note is only slightly in- 
creased. With a thick layer of plastic exu- 
dation the dulness is marked. 

Auscultation. — With dryness of the pleural 
surface the respiratory murmur is feeble, muf- 
fled, and jerky, with occasionally a friction 
sound, and with the appearance of exudation 
a friction sound is frequently present. A vari- 
ety of rales, crepitant, subcrepitant, coarse, 



72 DISEASES OF THE HEART AND LUNGS. 

and gurgling, are heard directly under the ear. 
They may all, or only one variety of rale, be 
present in the same case. If the pleurisy is 
diaphragmatic or mediastinal, the rales are 
more distant from the ear or not heard at 
all. If the adhesions are between the peri- 
cardium and the lung or chest wall, the rales 
may be synchronous with the movements of 
the heart and heard when the breath is held. 
With no motion of the affected side rales are 
absent. Vocal resonance may be increased or 
diminished. 

The plastic exudation may be almost imme- 
diately re-absorbed ; or the adhesions become 
firmer, the lung is bound to the chest wall 
or the mediastinum, the pericardium adheres 
to the lung, the heart becomes displaced, and 
functional murmurs may arise and lead to 
error in diagnosis. A variety of fine, coarse, 
dry, moist, crackling rales and creaking may 
be heard, or the lung may be so firmly bound 
to the chest wall as to allow little stretching 
of adhesions and rales will be absent and 
respiration feeble. Expiration may be pro- 
longed. 



PLEURISY. 73 

Pleurisy with Effusion. 

Pleurisy may run its course with or without 
the production of fluid. 

Inspection. — Motion over the affected side 
is restrained, with bulging of the intercostal 
spaces. 

Mensuration. — The affected side is enlarged. 

Palpation. — Absence of vocal fremitus over 
the fluid. 

Percussion. — Over the fluid, flatness ; at the 
level of the fluid, dulness ; over the lung, pul- 
monary resonance, tympanitic in character. 
If the effusion is moderate in quantity, and 
not confined by adhesions, the line of dulness 
is curved, being lowest next to the spine, 
highest in the axillary region, and lower 
towards the sternum. If the effusion of fluid 
is large, flatness is observed over the whole of 
the affected side. If there is compression 
without hepatization of the lung, a decided 
clearness of the percussion note is noticeable 
at the end of inspiration (Da Costa). 

Auscultation. — Over the fluid the respiratory 
and voice sounds and vocal fremitus are ab- 
sent. ^Egophony may be heard at the level 



74 DISEASES OF THE HEART AND LUNGS. 

of the fluid. Above the fluid and over the 
compressed lung we have harsh respiration, or 
bronchial breathing and bronchophony. The 
bronchial breathing and bronchophony are dis- 
tant, muffled, and non-metallic in character. 
If the effusion is large, no sounds are heard 
except at the apex, under the clavicle, and by 
the side of the spine. If the layer of fluid is 
thin and the lung bound to the chest wall by 
loose adhesions, the respiratory and voice 
sounds are heard over the fluid, but are feeble 
and distant. The respiration over the unaf- 
fected side is exaggerated. With change of 
position the level of the fluid is changed un- 
less it is confined by adhesions. The heart is 
displaced if the effusion is considerable, to the 
right if the effusion is on the left side, and 
vice versa. 

When absorption of the fluid occurs the 
bulging of the affected side gradually disap- 
pears. The percussion note slowly becomes 
normal, but dulness may remain permanently 
if the pleura is much thickened or if the con- 
densation of the lung tissue remains. The 
respiratory and voice sounds, at first feeble, 



H YDRO THORAX. 75 

become more distinct, and when the surfaces 
of the pleura come in contact a friction sound 
is heard, crepitating or creaking in character. 

EMPYEMA. 

The physical signs are the same as in pleurisy 
with effusion, namely, enlargement over the 
affected side and bulging of the intercostal 
spaces, flatness over and dulness at the level 
of the fluid, and pulmonary or tympanitic 
resonance above, absence of voice and breath 
sounds over the fluid, bronchial breathing and 
bronchophony or harsh respiration over the 
lung, and sometimes aegophony at the level of 
the fluid. 

If the effusion is abundant it may pulsate 
with the movements of the heart, — pulsating 
emphysema. Puncture by the hypodermic nee- 
dle demonstrates the presence of pus. 

HYDROTHORAX. 

Hydrothorax is an accumulation of fluid in 
the pleural cavity. It is bilateral, although 
more fluid may be on one side than on 
the other. The physical signs are the same 



j6 DISEASES OF THE HEART AND LUNGS. 

as in pleurisy with effusion and empyema. 
The level of the fluid is changed by altering 
the position of the patient, which is not always 
the case in the last two diseases, owing to the 
presence of plastic matter. 

HYDROPNEUMOTHORAX. 

Hydropneumothorax is an accumulation of 
air and fluid in the pleural cavity. 

Inspection. — Distention of the affected side, 
and bulging of the intercostal spaces. Absence 
of respiratory movements. 

Palpation. — Absence of vocal fremitus. 

Percussion. — Flatness below, and tympanitic 
resonance above, the level of the fluid. 

Auscultation. — Below the level of the fluid, 
absence of breath and voice sounds. If the 
layer of fluid is thin, the compression and dis- 
placement of the lung being prevented by 
adhesions, feeble respiratory and vocal sounds 
may be heard. Above the level of the fluid, 
amphoric respiration and voice and metallic 
tinkling are usually present. The amphoric 
sounds and metallic tinkling may be heard 
together, or either may occur alone and at 



PNE UMO THORA X. y/ 

different times in the same case. They denote 
an opening from the lung into the pleural 
cavity, and the intensity and pitch vary con- 
siderably with the tension of the chest walls 
and of the contained air and with the size of 
the opening. 

Succussion. — By resting the ear upon the 
chest and abruptly shaking the patient, we 
hear a metallic, splashing sound, which is the 
characteristic sign of the disease. 

PNEUMOTHORAX. 

Pneumothorax is an accumulation of air in 
the pleural cavity. 

Inspection. — Distention of the affected side, 
and immobility during respiration. 

Palpation. — Vocal fremitus feeble or sup- 
pressed. 

Percussion. — Tympanitic resonance. The 
pitch varies with the amount of air, the ten- 
sion of the walls of the cavity, and the com- 
pression of the contained air, the resonance 
sometimes being metallic or amphoric in 
character. 

Auscultation. — Respiratory and voice sounds 



78 DISEASES OF THE HEART AND LUNGS. 

are suppressed if the amount of air in the 
pleural cavity is large, but may be feebly 
heard if the amount is small. The heart 
sounds are obscurely transmitted. With an 
opening in the pulmonary pleura allowing the 
air to pass in and out, amphoric or cavernous 
respiration is heard. 

EMPHYSEMA. 

Inspection. — -When vesicular emphysema is 
not extensive nor far advanced, no change or 
only a slight bulging is observable. In ad- 
vanced cases bulging occurs above and below 
the clavicles, with prominence of the intercos- 
tal spaces, giving the chest the characteristic 
round or "barrel-shaped" appearance, while 
the lower part of the thorax is drawn in. The 
chest has somewhat the appearance that it has 
normally at the end of a full inspiration, and 
expansion and contraction are scarcely per- 
ceptible, while inspiration is labored, chiefly 
abdominal, the lower part of the thorax being 
drawn in instead of expanded with each in- 
spiration. In some well marked cases, more 
especially in old people, the lung is atrophied 
and no projection of the chest wall is observed. 



ASTHMA. 79 

Palpation. — Vocal fremitus is increased, di- 
minished, or unchanged. The apex beat of the 
heart may be absent or lower than normal. 

Percussion. — The pulmonary quality of the 
percussion note is diminished and more or less 
tympanitic. It has been called vesico-tym- 
panitic. The pitch may be raised or lowered, 
and depends upon the condition of the lung 
and degree of distension and tension of the 
chest wall. The percussion notes differ slightly 
at the extremes of respiration. 

Auscultation. — Expiration is prolonged usu- 
ally to a marked degree ; inspiration is short- 
ened or even suppressed, the pitch of both 
being lower than in health. Respiratory sounds 
are feeble. In some cases the bronchial ele- 
ment of the inspiration is exaggerated and 
we have harsh respiration. Vocal resonance 
is unchanged, increased, or diminished. The 
heart sounds are feeble, and in general and 
advanced emphysema the organ itself is pushed 
downward. 

ASTHMA. 

Between the paroxysms either the physical 
signs are normal, or those of emphysema or 
bronchitis, or of both are present. 



80 DISEASES OF THE HEART AND LUNGS. 

Inspection. — During the paroxysm the chest 
is distended in a condition of extreme inspira- 
tion, and the respiration is labored, with little 
change in the size of the thorax during the 
respiratory acts. The respirations are pro- 
longed, so that only about half the normal 
number occur per minute. 

Palpation. — Vocal fremitus normal. 

Percussion. — Normal or exaggerated pulmo- 
nary resonance. 

Auscultation.- — The respiratory murmur is 
jerking or irregular. The vesicular element 
is feeble or suppressed ; the bronchial element 
usually feeble or suppressed, but in some cases 
exaggerated. Sibilant and sonorous rales 
of varying intensity, pitch, and quality, are 
heard all over the chest and sometimes even 
at a distance. Coarse, moist rales of bron- 
chitis or pleurisy may be present. 

PULMONARY CEDEMA. 

Inspection. — Respiration labored. 
- Palpation. — Vocal fremitus may be slightly 
increased. 

Percussion. — With a small amount of serum 



HEMOPTYSIS. 8 1 

in the lung little or no dulness is observed, 
but if the infiltration is considerable dulness 
becomes marked. 

Auscultation. — The vesicular element of the 
respiratory murmur is feeble or absent. The 
bronchial element is either feeble or harsh. 
Coarse, moist rales are heard, and often crepi- 
tant rales. 

Crepitant rales are usually given as a sign 
of pulmonary oedema, but if their origin is ad- 
mitted to be in the pleura, they can no longer 
be recognized as a sign of this condition. 
Their occurrence is easily accounted for by 
the fact that pleuritic exudation is a frequent 
accompaniment of oedema of the lungs. 

HAEMOPTYSIS. 

Haemoptysis is not a disease, but a symptom 
of disease, and accompanies many different 
conditions. In the great majority of cases it 
is due to a weakening or loss of tonicity in 
the walls of the blood-vessels of the bronchi 
or to their rupture, which allows the blood 
to pass through, sometimes in considerable 
quantities. By some interference with the 



82 DISEASES OF THE HEART AND LUNGS. 

circulation, such as occurs in phthisis or 
cardiac disease, the vessels are unduly filled 
and the blood is forced through the bronchial 
walls. Sometimes breaking down of lung 
tissue and actual rupture of large blood- 
vessels occur. The blood expectorated may 
be bright red or dark in color. After having 
lain for a considerable period in the bronchial 
tubes or in cavities in the lungs before being 
expectorated it is frequently dark-colored or 
almost black. On auscultation large and small 
bubbling rales may often be heard. 

Bleeding may occur from other parts and 
lead us to suppose that it is from the lungs. 
When it comes from the mouth, throat, or 
nose, the fact can usually be determined by 
examining those parts. The blood from the 
posterior nares is generally in clots and dark- 
colored, and unaccompanied by cough. If it 
be from the stomach, it is vomited, has an 
acid smell, and is commonly dark-colored ; in 
this case the nausea and vomiting precede the 
hemorrhage. If in bleeding from the lungs 
nausea and vomiting occur, they come after 
the hemorrhage has commenced. 



PULMONARY PHTHISIS. 83 

PULMONARY CONGESTION. 

Many authors assert that pulmonary con- 
gestion cannot be recognized by physical 
signs. 

Percussion. — The pitch of the normal per- 
cussion note is lowered. 

Auscultation. — The vesicular element of the 
respiration is feeble and muffled. The bron- 
chial element is of raised pitch and decreased 
intensity. 

ACUTE MILIARY TUBERCULOSIS. 

Miliary tubercles may be present in the 
lungs even in considerable abundance without 
giving any physical signs, and it then becomes 
necessary to make our diagnosis by other 
means. In some cases, however, in addition 
to the symptoms the percussion note is low- 
ered in pitch, and on auscultation the vesicu- 
lar element of the respiration is feeble and 
the bronchial element harsh. 

PULMONARY PHTHISIS. 

In no disease is a careful consideration of 
the history of the patient of more importance 



84 DISEASES OF THE HEART AND LUNGS. 

to enable us to arrive at a correct interpreta- 
tion of the physical signs. 

The modern classification of phthisis into 
fibroid, catarrhal, and tubercular has with 
most authors superseded the old view that all 
phthisis is tubercular. In many cases, in what- 
ever way the initial stage began we find later 
the three conditions of catarrh, of fibroid indu- 
ration, and of tuberculous deposits existing 
together. 

The physical signs of fibroid phthisis in its 
earlier manifestations are the same as in 
chronic bronchitis and pleurisy with thickened 
pleura and pleuritic adhesions. Later, fibroid 
induration of lung tissue, the presence of 
caseous masses, their softening and the forma- 
tion of cavities give the same physical signs as 
the other forms of phthisis. 

For purposes of physical diagnosis it is con- 
venient to consider cases of phthisis in three 
groups : 

i. Those in which the disease first gives 
evidence of its presence by physical signs. 

2. Those in which the disease has advanced 
to well marked consolidation or softening. 



PULMONARY PHTHISIS. 85 

3. Those in which cavities exist. 

1. Inspection in the first group gives little in- 
formation. In the majority of cases phthisis 
begins at the apex. The supra- and infra- 
clavicular regions are unchanged or slightly 
flattened, unless the consolidation is consider- 
able. Marked flattening with slight consolida- 
tion is evidence of the presence of pleuritic 
adhesions. Expansion on the affected side is 
noticeably interfered with early in the case. 
The lack of expansion is a more valuable sign 
in females than in males, it being naturally 
more limited in the latter under the clavicles. 
The slight and momentary elevations of skin 
produced in some persons by a sharp tap on 
the chest wall, and known as myoidema, are 
seen not only with phthisis but in other condi- 
tions as well. 

Palpation. — Sometimes we notice lack of 
expansion best by palpation. Vocal fremitus 
is increased to a trifling degree, usually more 
noticeably in men than in women. Remem- 
ber that vocal fremitus is normally more 
marked under the right than under the left 
clavicle. 



86 DISEASES OF THE HEART AND LUNGS. 

Percussion. — Slight dulness and increased 
resistance to the percussing finger at either 
apex are valuable signs. These signs are im- 
portant either behind or in front in the supra- 
and infra-clavicular regions, where they are 
more commonly observed on account of the 
comparative thinness of the chest wall, and the 
dulness is earliest noticed at the inner third of 
the latter. Recollect that the percussion note 
is relatively somewhat duller under the right 
clavicle than on the opposite side in the nor- 
mal chest, and also that deformity, or any po- 
sition of the patient which destroys the sym- 
metry of the two sides, affects the percussion 
note. Lateral curvature of the spine produces 
dulness on the side towards which it is directed. 
Slight dulness is a more valuable sign in the 
female than in the male. Localized pulmonary 
emphysema sometimes gives us increased pul- 
monary resonance over the affected portion of 
the lung. 

Auscultation. — The results obtained by aus- 
cultation vary widely in different cases. 
Changes in the respiration in the suprascapu- 
lar region or above or below the clavicle, and 



PULMONARY PHTHISIS. 87 

not extending downward for any considerable 
distance, are often of more importance than 
corresponding changes over other regions. In 
commencing phthisis the vesicular element of 
the respiration is feeble ; the bronchial is 
feeble or almost suppressed, or harsh, raised in 
pitch, and heard with considerable intensity in 
inspiration and with less intensity and lower 
pitch in expiration, or both the pitch and in- 
tensity may be increased in expiration. The 
degree of harshness varies within wide limits 
from a slight change from normal respiration 
to extreme harshness approaching bronchial 
breathing. In the latter case expiration is 
harsher and higher-pitched than inspiration, 
and expiration may be considerably prolonged. 
The character of the respiration is not the 
same over wide areas, but in some localities 
near the apices may be harsh and in others 
feeble. In forming an opinion the normal 
difference between the two apices must not be 
forgotten. Prolonged expiration when accom- 
panied with change of quality and of pitch is 
an important sign, but otherwise, more espe- 
cially under the right clavicle and in women, is 



SB DISEASES OF THE ttBA&T AND LUNGS. 

not of great value. Breezy, wavy, cog-wheeled 
respiration, when localized and when we can 
exclude the presence of pleuritic adhesions as 
a cause, is a corroborative sign of some value. 

Vocal and whispering resonance and vocal 
fremitus are usually increased, but these signs 
are somewhat uncertain and their absence is 
not of much significance. The heart sounds 
conveyed to the apex with abnormal intensity, 
more especially the first sound heard with 
greater intensity at the right than at the left 
apex, is corroborative evidence of phthisis. 

Besides the signs of early phthisis, already 
mentioned, valuable accessory evidence is often 
obtained from pneumonia, bronchitis, emphy- 
sema, and pleurisy, localized at the apex. 

2. When the disease becomes more advanced, 
consolidation occurs over sufficient areas to 
give well-defined physical signs, and still later 
the consolidation softens and breaks down. 

Inspection. — Depression above and below 
one or both clavicles, becoming in time marked. 
Increased frequency of the respirations, with 
less mobility of the chest over the affected 
parts, more especially at the apices. 



PULMONARY PHTHISIS. 89 

Percussion. — Dulness, often wooden or tubu- 
lar in character, is marked and widespread, 
according to the extent of the consolidation. 

Auscultation. — Small areas of consolidation, 
separated from the chest wall by healthy or 
emphysematous lung, will give signs that have 
already been considered ; but considerable 
areas of consolidation, extending to the sur- 
face of the pleura, give bronchial breathing, 
bronchophony, and bronchial whisper, all vary- 
ing in intensity in different cases, more es- 
pecially the latter two signs. Rales are heard, 
often metallic and high-pitched, moist or dry, 
and produced either in the pleura or within 
the lung. 

3. After cavities are formed, we have addi- 
tional physical signs. 

A small cavity filled with fluid, or even with 
air, more especially if it be some distance from 
the surface, cannot invariably be recognized. 

Inspection. — The signs remain the same as 
before. Exceptionally there is less depression 
or even bulging of the chest wall over the 
cavity, and more marked expansion with the 
respirations. 



90 DISEASES OF THE HEART AND LUNGS. 

Percussion. — Dulness, tympanitic, amphoric, 
and cracked-pot resonance. The percussion 
note varies with the condition of the cavity 
and of the surrounding parts. If normal lung 
tissue intervenes between a small cavity and 
the chest wall, percussion elicits pulmonary 
resonance, and if the cavity be surrounded by 
sufficient induration, or full of fluid, the percus- 
sion note is dull. Large cavities near the chest 
wall give tympanitic, amphoric, or cracked- 
pot resonance. Large cavities with thin walls, 
more especially if the walls are tense by adhe- 
rence to the costal pleura, give amphoric res- 
onance. Cracked-pot resonance is a sign that 
an open bronchial tube leads into the cavity. 1 

Auscultation. — Bronchial, cavernous, and 
amphoric respiration, metallic tinkling, vocal 
and whispering bronchophony, pectoriloquy, 
and gurgling rales. 

1 A cracked-pot sound is heard over the chest of some children in 
whom the chest walls are thin and yielding, and the air is therefore 
easily expelled from the bronchial tubes by percussion. Still more 
rarely is this possible in adults. Instances are recorded by Walshe of 
cracked-pot sound heard over consolidation with a small cavity, not 
larger than a walnut, an inch or two distant ; also over the consolida- 
tion of pneumonia, and also under the clavicle in cases of pleurisy 
with effusion. 



PULMONARY PHTHISIS. 9 1 

Bronchial breathing is only heard over small 
cavities. Cavernous respiration is heard over 
large or small cavities and amphoric over large 
cavities, the former when the walls are soft 
and yielding, the latter when they are tense 
and unyielding. The pitch varies with the 
size of the cavity and the tension of its walls. 
Metallic tinkling is sometimes heard over 
cavities of large size. Large- or small-sized 
gurgling rales may be heard over cavities. 
Rales produced within the pleura are inten- 
sified by the cavity beneath. Vocal and 
whispering bronchophony and pectoriloquy 
are heard over cavities, but vary in intensity, 
and may be feeble or absent. The heart 
sounds may be heard with increased intensity 
over cavities, more especially over those at 
the apices of the lungs. 

The determining of the size, form, and 
condition of cavities. 1 — In some cases, at the 

1 It is perhaps sufficient for the general practitioner to be able to 
recognize the presence of a cavity, and any attempt to go further may 
be considered by some as an over-refinement in diagnosis, " but is it 
not rather an attempt at a scientific interrogation of nature in the 
cause of suffering humanity ? " — Dr. G. P. Cammann's posthumous 
papers. In my remarks upon cavities, I have borrowed somewhat 
extensively from a paper by my father published after his death. 



92 DISEASES OF THE HEART AND LUNGS. 

time of the examination the cavity is filled 
with fluid, and therefore impossible to recog- 
nize by physical signs, as practically no cavity 
is there. If, then, the rational signs indicate 
the presence of a cavity, it will be well either 
to change the time for seeing the patient from 
morning to evening or vice versa, or else to 
cause the patient to change his position long 
enough to partially or wholly empty the cavity. 

The size a-nd form of a cavity can be pretty 
accurately determined by auscultation and per- 
cussion, or better by auscultatory-percussion. 
Sometimes several cavities will be connected 
together, each one having its own character- 
istic signs. 

If a bronchus opens into a cavity, empty, 
with firm, unyielding walls, the respiratory 
sound will be low-pitched, prolonged, and with 
a sensible jar from the vibration of its walls. 
If the cavity contains fluid, as it may if the 
opening into the bronchus be above the floor, 
or even if the opening be in the floor and ex- 
ceedingly small, the sound will be raised in 
pitch and the jar of the vibrating walls dimin- 
ished, while if the opening be in the floor 



PULMONARY PHTHISIS. 93 

bubbles will be heard breaking in the cavity, 
resounding and amphoric in character. If the 
cavity have flexible walls and be empty, the 
cavernous respiration will be unaccompanied 
by the jar of vibrating parietes, will be short, 
and sometimes have a flapping character. 
With fluid there will be gurgling, more or less 
raised in pitch according to the amount of the 
fluid. 

If the opening into a cavity be through a 
bronchus in the side wall, and the bronchus is 
pervious on both sides, the air will pass 
through the cavity. If the cavity be empty, 
with unyielding walls, and surrounded by dense 
lung tissue, the sound will be loud and blow- 
ing, with a sensible jar. If the walls be yield- 
ing and soft the sound will still be blowing, 
but softer in character and without the jar. 
With fluid there will be coarse, moist, and 
gurgling rales, and the blowing will be loud 
and the jar diminished if the walls are firm ; 
and if the walls be yielding the blowing will be 
less loud, softer, and sometimes have a flapping 
character, while the jar will be absent. 

We can often gain valuable knowledge from 



94 DISEASES OF THE HEART AND LUNGS. 

change in the position of the patient. If a 
patient coughs equally in any position we 
know that he has a cavity or cavities so placed 
that in whatever position he may be secretion 
is continually being poured into the bronchial 
tubes. If he coughs most in the erect position, 
and is for a time relieved by reclining, he has 
a cavity so placed that in the former position 
it is continually discharging into the bronchial 
tubes, while in the latter the cavity ceases to 
discharge, and until it is filled to overflowing 
the patient has rest. If he coughs most when 
reclining and little when up, the reverse is the 
case. If the patient lies on one side and 
coughs continually in that position, by lying on 
the opposite side he may obtain rest until the 
cavity fills to overflowing. If the cough only 
occurs in the morning after a quiet night the 
cavity is so situated that it ceases to discharge 
when he reclines, but when he rises empties 
itself and then causes more or less cough during 
the day according to the amount of the secre- 
tion. If a cavity be partially filled with fluid, 
we can often determine the position of the 
opening by changing the position of the patient, 



PULMONARY PHTHISIS. 95 

and so bringing the opening above or below 
the surface of the fluid, developing in either 
case the appropriate physical signs. 

The cough will also be modified by the size 
of the opening from the cavity, whether it be 
large or small. In the former the secretion 
will flow readily, while in the latter some time 
will elapse before the discharge commences, 
or perhaps it will have to be forced out by 
over-distension of the cavity. The consist- 
ence of the secretion will also affect the ra- 
pidity of the flow, a thick secretion requiring 
a larger opening to flow from the cavity with 
the same rapidity as a thin fluid. We may 
have more than one opening, so that the air 
can enter by one while the secretion flows 
from another. If the cavity have firm walls, 
the secretion may only flow when the cavity is 
distended. If the walls be elastic, the action 
of the lungs upon them may continually empty 
the cavity. The physical conditions may 
change from time to time by new openings 
or new cavities being formed, and by carefully 
studying these changes we may do much for 
the comfort of the patient. 



96 DISEASES OF THE HEART AND LUNGS. 

Bacillus of Tuberculosis. — The presence of 
the bacillus of tuberculosis in the sputa is a 
valuable aid in diagnosis, and is often the 
first positive evidence of the presence of 
phthisis. 

ATELECTASIS AND PULMONARY COLLAPSE. 

The lungs are normally in a condition of 
atelectasis in fcetal life. After birth the air 
may partially or totally fail to enter some of 
the alveoli. If the condition is acquired after 
the lung has been fully expanded it is called 
pulmonary collapse or compression. So small 
a portion of the lung may be deprived of air, 
and at the same time be so far removed from 
the surface of the chest that the condition is 
not appreciable by physical signs, or we may 
detect only a slight feebleness or muffling of 
the respiration. Other cases in which more 
extensive areas are involved show on inspec- 
tion lack of expansion and a sinking in of the 
lower part of the chest with inspiration. 

Percussion. — Dulness, slight or marked, ac- 
cording to extent of area involved. If com- 
pensatory emphysema is developed around the 



PULMONARY APOPLEXY. g? 

collapsed areas, we have the percussion note 
of emphysema. 

Auscultation. — The vesicular element of the 
respiration is feeble or absent, while the bron- 
chial element is feeble, absent, or harsh, or 
with considerable areas involved we have 
bronchial breathing, bronchophony, and in- 
creased vocal fremitus. Rales due to bron- 
chitis may be heard. 

PULMONARY INFARCTION. 

We may have no physical signs, or the vesic- 
ular element of the respiration may be feeble, 
or localized dulness on percussion may occur 
over the seat of the infarction, and on auscul- 
tation harsh or bronchial respiration. 

PULMONARY APOPLEXY. 

Effusion of a considerable or large amount 
of blood from a ruptured pulmonary artery 
with laceration of the lung tissue. 

This condition may give no physical signs. 
With large effusion inspection and palpation 
give no signs except that vocal fremitus may 
be decreased. The percussion note may be 



98 DISEASES OF THE HEART AND LUNGS. 

somewhat dull, and on auscultation the breath 
and voice sounds feeble and muffled over the 
area corresponding to the extravasation. Moist 
bronchial rales may be heard. If there be ac- 
companying pneumonia, appropriate physical 
signs are developed. 

PULMONARY GANGRENE. 

The physical signs # are not characteristic. 
They are those of consolidation over an area 
more or less extended according as the gan- 
grene is circumscribed or diffused. Bronchitis 
and pleurisy may be associated with this con- 
dition. Later, signs of a cavity appear. 

CANCER OF THE LUNGS. 

Any variety of cancer may occur in the 
lungs. It is usually secondary. The lungs 
alone may be affected, or disease of the bron- 
chial glands and tumors of the mediastinum 
also be present. The endless variety of posi- 
tion and shape which the cancerous masses 
may assume cannot be considered in detail. 
Their pressure upon the nerves, blood-vessels, 
air passages, organs, and chest wall gives ap- 



CANCER OF THE LUNGS. 99 

propriate symptoms. The bronchial glands, if 
enlarged sufficiently, give the physical signs 
of mediastinal tumors. 

The miliary form of cancerous growths in 
the lungs often cannot be recognized. The 
vesicular element of the respiration may be 
feeble, and we have the signs of bronchitis. If 
the growths be nodular, the physical signs will 
vary with the size, position, and number of the 
nodules. By inspection, if the growth be con- 
siderable, the chest may be seen to expand, 
but not uniformly, and motion over the affected 
side is diminished or abolished. Vocal fremi- 
tus may be diminished or absent. The 
percussion note is more or less dull. On aus- 
cultation respiratory and voice sounds may be 
feeble or absent, or bronchial breathing and 
bronchophony may be heard. The voice 
sounds, however, vary considerably. The 
heart sounds may be transmitted with in- 
creased intensity. By auscultatory-percussion, 
percussion being practised in front and auscul- 
tation behind, or the reverse, the percussion 
note will be high-pitched and of great inten- 
sity, and some idea can be formed of the posi- 



IOO DISEASES OF THE HEART AND LUNGS. 

tion and size of the mass, especially if it 
touch the chest wall at any point. 

With cancerous infiltration we have retrac- 
tion of the affected side. If the pleura be 
involved a friction sound, or the physical signs 
of plastic exudation, or fluid in the pleural 
cavity are present. 

The signs of a mediastinal tumor are some- 
what similar to those of masses within the 
lungs, If it encroaches upon the chest wall 
local bulging is observed and vocal fremitus is 
absent, unless the mass lies upon the trachea 
or a large bronchial tube. If it lies upon the 
aorta or heart we have a transmitted impulse. 
The percussion note is usually dull, but we 
may have the transmitted percussion note of 
adjacent parts. We may on auscultation hear 
nothing, or feeble respiratory sounds, or simi- 
lar sounds to those heard over consolidated 
lung on account of the mass pressing upon a 
main bronchus and transmitting bronchial 
breathing and bronchophony. The heart 
sounds may be conveyed with great intensity 
and a murmur produced by pressure upon the 
aorta or pulmonary artery. By a2tscultato7y- 



CANCER OF THE LUNGS. IOI 

percussio7i the tumor can readily be mapped 
out if it touch the chest wall, or by auscultating 
in front or behind and percussing on the 
opposite side of the chest we can estimate 
from the intensity and character of the sound 
the size and position of the tumor. 



THE HEART. 



SECTION IV. 

POSITION OF THE HEART. 

An acquaintance with the positions of differ- 
ent organs, and the changes in position which 
they may undergo under varying circumstances 
in health, is often necessary in order to appre- 
ciate the presence of morbid conditions. The 
results obtained from the dissection of frozen 
bodies have been taken as absolute guides, but 
Sibson has clearly demonstrated that such re- 
sults are not applicable to the living body. To 
describe the heart as occupying one position is 
a mere expression of a dead anatomy. It is con- 
tinually changing with its own movements and 
with each act of respiration, and is differently 
situated in well and poorly developed chests. 

Average Position. — Let us now consider one 
position, which is, as nearly as may be, the 
mean between extreme variations that the 




Figure io. 
showing position of heart and great vessels. (quain's " anatomy. 



104 DISEASES OF THE HEART AND LUNGS. 

heart occupies in the chest of a well-formed, 
healthy person, and call this the average posi- 
tion. The heart lies obliquely within the 
cavity of the chest, with a general direction 
from the base downward, forward, and to the 
left to the apex. Nearly one third lies in the 
right cavity of the chest or to the right of the 
median line, and two thirds on the left side. 
The transverse diameter of the heart in its 
widest part equals about one half the breadth 
of the thoracic cavity, and in its antero- 
posterior diameter occupies most of the space 
between the sternum and the vertebrae. The 
upper border lies behind the third left costal 
cartilage and the sternum at the same level. 
The apex is situated in the fifth intercostal 
space, within a vertical line passing through 
the nipple, or about two and a half inches from 
the middle line of the sternum. The right 
border extends in a curved line from the base 
to the lower border, reaching at its farthest 
point to the right about one inch from the 
edge of the sternum. The lower border of 
the heart passes from the extremity of the 
right border behind the sixth right costal 




Figure ii. 
showing heart. great vessels, diaphragm, etc., exposed. 

(SIBSON.) 
I05 



I06 DISEASES OF THE HEART AND LUNGS. 

cartilage near the sternum slightly downward, 
and to the left behind the ensiform cartilage 
about a half an inch below the lower end of 
the sternum, and terminates at the apex. The 
left border extends from the apex and lies for 
the greater part behind or to the left of a 
vertical line passing through the nipple. The 
base of the heart is formed by the auricles, 
the right auricle lying behind the sternum 
between the third costal cartilages and ex- 
tending downward for a considerable distance 
to the right of that bone. The appendix of 
the left auricle lies behind the third left costal 
cartilage. The right ventricle forms the 
greater part of the front of the heart and is 
wedged in as it were between the right auricle 
which lies to the right, and a little above, and 
the narrow edge of the left ventricle which 
forms the left border of the heart ; the right 
ventricle itself forming the lower border. The 
only portion of the left ventricle seen from in 
front is a narrow strip running from the 
appendix of the left auricle above to the apex, 
widest near its middle behind the fourth inter- 
costal space, where it is about one fifth of the 




1 



■% ■ 



Figure 12. 
side view of heart and great vessels. (_slbson.) 

I07 



108 DISEASES OE THE HEART AND LUNGS. 

breadth of the heart, and narrowing from this 
point towards either extremity. 

When the heart is in the position just de- 
scribed the mitral orifice lies behind the left 
half of the sternum, on a level with the fourth 
cartilage and its intercostal space, the aortic 
orifice lying behind the left half of the ster- 
num, on a level with and extending partly 
into the third intercostal space. The pul- 
monary orifice lies behind the third left costal 
cartilage and the adjoining edge of the ster- 
num, while the tricuspid orifice is behind the 
right half of the sternum, on a level with the 
fifth costal cartilage. 

If we consider the valvular orifices with re- 
gard to the position from before backwards, 
the tricuspid is found to be farthest in front, 
or most superficial, the pulmonic is next be- 
hind, the aortic orifice third in order, and the 
mitral the farthest back. 

The aorta at its commencement lies con- 
cealed in the heart and first comes into view 
behind the sternum, on a level with the third 
costal cartilages, its right border lying behind 
or a little to the left of the right border of the 




Figure 13. 

light auricle and ventricle exposed showing valves, 
(quain's "anatomy.") 



IO9 



IIO DISEASES OF THE HEART AND LUNGS. 

sternum, and its left border, partially over- 
lapped by the pulmonary artery, lying some- 
what to the right of the left border of that 
bone. As it ascends it bears to the right and 
lies partially behind the second costal cartilage. 




Figure 14. 
isase of ventricular part of heart, showing relative position 
of the arterial and ventricular orifices. (quain's 
"anatomy.") 5. tricuspid orifice. 6. mitral orifice. 
7. pulmonic orifice. 8. aortic orifice. 

Looking at the heart from behind, the lower 
boundary of the left ventricle is about on a 
level with the spine of the ninth and the 
upper part of the body of the tenth dorsal 




i'lGURE 15. 

HEART AND VESSELS AS SEEN FROM BEHIND. (SIBSON. 

Ill 



112 DISEASES OF THE HEART AND LUNGS. 

vertebrae. The boundary line separating the 
heart and the great vessels and passing over 
the upper border of the left auricle lies in 
front of the spine of the fifth and lower bor- 
der of the body of the sixth dorsal vertebrae. 
The mitral orifice is in front of and to the left 
of the spines of the sixth and seventh and the 
bodies of the seventh and eighth dorsal verte- 
brae, or a little above a line joining the inferior 
angles of the scapulae. The orifice looks tow- 
ards the apex of the left ventricle in a direc- 
tion towards the left, forward, and slightly 
downward, so that in mitral incompetence the 
column of blood is regurgitated from left to 
right, backward and slightly upward. 

Variations in the Position of the Heart. — 
Although the mean position, as it were, has 
just been described, the heart is continually 
changing, and a knowledge of these varia- 
tions is absolutely necessary to the clinical 
worker Not only is the organ itself moving 
and changing its form by its own contractions 
and relaxations, but the chest is varying in 
dimensions with the respiratory acts. During 
the systole of the ventricles the auricles are 



THE HEART. II3 

distended with blood, while the walls of the 
ventricles contract and the apex of the heart 
passes forward, upward, and to the right. Dur- 
ing diastole the reverse occurs, the auricles 
shrink while the ventricles become distended, 
and the apex falls downward, backward, and 
to the left. The position of the heart in rela- 
tion to the walls of the chest changes with 
each respiratory act. With a forced inspira- 
tion the heart descends with the diaphragm 
for about an inch, while the anterior and la- 
teral walls of the chest ascend, so that at the 
end of inspiration the apex lies behind the 
seventh costal cartilage, while the base lies on 
the line of the lower boundary of the third 
intercostal spaces. At the end of a forced 
expiration, on the other hand, the apex is 
often felt in the fourth intercostal space, while 
the upper boundary of the base lies on a line 
joining the second intercostal spaces. The 
impulse of the right ventricle, which at the 
end of expiration is perceptible to the left of 
the lower end of the sternum, is at the end of 
inspiration felt in the epigastrium ; when the 
respiration is not forced, the cardiac move- 



114 DISEASES OF THE HEART AND LUNGS. 

merits, in both directions, are within narrower 
limits. 

In strong, well developed persons leading 
an active life, the amount of reserve air in the 
lungs is always considerable, the chest is broad 
and deep, and the position of the heart with 
reference to the chest wall is low, or, in other 
words, the normal position approaches that 
which the heart naturally assumes at the end of 
inspiration. On the other hand, in feeble, 
poorly developed persons, the reserve air in the 
lungs is small in amount, the chest is narrow 
and shallow, the diaphragm lies high, and the 
position of the heart is high, or approaches that 
naturally occupied at the end of expiration. In 
women, especially in those who lead a seden- 
tary life and spend most of the time sewing, the 
heart is apt to lie high, the apex perhaps being 
felt in the fourth intercostal space. In those 
women, too, who wear tight corsets, although 
the upper part of the chest may be well 
developed and expand freely, the diaphragm 
will lie high and the apex be correspondingly 
elevated. In children the situation of the 
heart is naturally high. The position varies 



THE HEART. 1 1 5 

somewhat in the same individual at different 
times. Thus after great and prolonged exer- 
tion, when more blood has passed through the 
heart, and the lungs have been fully expanded, 
the heart is relatively low, while, on the other 
hand, after prolonged rest, when a compara- 
tively small amount of air has entered the 
lungs, its position is relatively high. 

The extent to which the heart is covered by 
the lungs in front varies greatly not only in 
different people, but in the same person during 
respiration. The size of the superficial or un- 
covered area is in inverse ratio to the size of 
the lungs. Striking as nearly as may be an av- 
erage between the extreme boundaries of this 
superficial cardiac region, the upper boundary 
may be described as lying behind the fourth 
left costal cartilage, the right behind the left 
half of the sternum on a level with the fifth 
costal cartilages ; passing to the left for about 
two inches the left boundary is reached. These 
three sides of the superficial cardiac region are 
bounded by the lungs ; below lie the dia- 
phragm, stomach, and liver. 

Inspection. — The form of the healthy chest 



Il6 DISEASES OF THE HEART AND LUNGS. 



is familar to every one. A slight bulging over 
the cardiac region and depression below are 
sometimes observed in health. The apex beat 
may be seen in the fifth interspace, about mid- 
way between the sternum and a vertical line 
from the nipple, as a brief, regular raising of 
the integument over a space not exceeding an 




Figure 16. 
cammann's cardiometer. 



inch square. The lower border of the pecto- 
ralis major muscle is a guide to the position of 
the fifth rib. In thin persons the apex beat is 
distinct, but in the fleshy scarcely perceptible. 
The position of the apex, however, is variable ; 
it rises and falls with the respiration ; it changes 
with the position of the patient, and is raised 



THE HEART. \\J 

by a distended stomach or intestines, or by 
any cause which elevates the diaphragm. In 
the robust it is low, while in feeble, narrow- 
chested persons it lies high. When the heart 
is low the impulse of the right ventricle can be 
seen in the epigastrium. 

In disease a bulging over the region of the 
heart may be caused by hypertrophy, or by 
fluid in the pericardium. Pericardial adhesions 
may occasion a drawing in of the chest wall 
with each apex beat. The apex may be dis- 
placed upward, downward, or to either side. 
The causes of such displacement lie in enlarge- 
ment of the heart itself, in pressure from 
without, as in the case of abdominal tumors 
or pleuritic effusion, or in contraction of 
adhesions. 

Palpation. — The sense of touch is of more 
value than sight in physical diagnosis. The 
apex beat can often be felt in fat persons, or 
when the heart is acting feebly, when its posi- 
tion cannot be seen. The impulse, too, may 
be analyzed and the force measured. At times 
two impulses can be felt — the one systolic, the 
other diastolic. The sounds of the heart may 



Il8 DISEASES OF THE HEART AND LUNGS. 

be felt — the one a long and dull, the other a 
short and distinct vibration. " The motion is 
due to the play of the valves, and disappears with 
their destruction." (Da Costa.) The impulse is 
felt best when the patient is sitting or standing 
and leaning forward, and its force is temporarily 
increased by exercise or forced respiration. 
Digestion or mental emotion have the same 
effect. In females with large breasts it is 
often difficult to detect the apex beat. The 
breast should be raised to allow the fingers 
more nearly to approach the chest-wall. 

Hypertrophy increases the force and extent 
of the beat. In dilatation it is diffused and 
feeble. Fatty degeneration or a feeble condi- 
tion of the system weaken the apex beat, as 
does also a portion of the lung intervening 
between the apex and the chest wall. With 
adherent pericardium the impulse may be con- 
fused and split up, as it were, into several 
parts. A thrill may be felt at the apex. 

Percussion. — The general rules applicable to 
percussion will be found in an earlier part of this 
work, and need not be repeated. They apply 
equally to percussion over the heart and over 



THE HEART. II9 

the lungs. The outline of the heart can be 
detected readily by auscultatory-percussion, if 
not by percussion. 

The percussion note over the superficial 
area of the heart is dull. The shape is irreg- 
ularly quadrangular. The dimensions of the 
area vary inversely with the size of the lungs. 
In fact the variation is so great, not only with 
the respiration and in different individuals in 
health, but also in disease of the heart itself 
and of the lungs, that any attempt to define 
the boundaries of the space is but an approxi- 
mation to the truth. The percussion^ note is 
lowered in pitch in passing from the liver to 
the heart. Where the heart is covered by the 
lungs, is found dulness on percussion. It is 
best to begin percussing over the lungs and 
gradually approach the edge of the heart. 
The percussion note is not at first much raised 
in pitch, but becomes more and more dull as 
the superficial area is reached. Sometimes it 
is impossible to find the border by percussion. 
Usually the upper border of the heart is behind 
the third left costal cartilage, and the lower 
border below the sternum behind the xiphoid 



120 DISEASES OF THE HEART AND LUNGS. 

appendix. To find the latter by percussion is 
difficult or impossible, but all that is practically 
necessary is to find the other three. The right 
boundary at the'level of the fourth rib extends 
to the right of the sternum about one inch, 
and the left border behind or to the left of a 
vertical line through the nipple. If these 
points and the position of the apex be ascer- 
tained we can draw a pretty accurate inference 
as to the size of the heart. The heart in its 
natural condition is about equal in size to the 
closed hand of the individual, and by placing 
the hand upon the chest it may be made to 
assume a position closely corresponding to the 
position of the heart beneath. (Laennec.) 
Considerable changes in the position of the 
heart and therefore in the percussion note are 
compatible with health, as will be seen by 
referring to the previous pages. 

To properly appreciate the meaning of the 
sounds elicited by percussion we must be able 
to analyze them and to understand the acoustic 
laws by which they are governed. In every 
percussion note the acoustic elements termed 
quality, intensity, pitch, and duration are to be 



THE HEART. 12 1 

considered. Acoustic laws have been briefly- 
glanced at with auscultation of the lungs, and 
the remarks there made apply equally to the 
sounds elicited by percussion and auscultation 
of the heart. 

It is sometimes of importance to mark out 
the area of aortic dulness. This is simply a 
rounded projection above the heart and con- 
tinuous with the cardiac dulness. Over the 
innominate artery scarcely any appreciable 
change is produced in the percussion note, 
while over the left carotid and left subclavian 
arteries no change whatever is perceptible. 
This is due to what is called the inflection of 
sound, by which sonorous waves embrace a 
non-resonant body on all sides and render 
the dulness of a small one inappreciable. 
(Balfour.) 

The area of cardiac dulness may be de- 
creased in emphysema or by pleuritic adhe- 
sions binding the lung to the chest wall, or 
less commonly by atrophy of the heart. In 
cases of air in the pericardium dulness is dimin- 
ished or entirely lost and replaced by tym- 
panitic resonance. The area of dulness is 



122 DISEASES OF THE HEART AND LUNGS. 

increased by enlargement of the heart, hyper- 
trophy or dilatation, or by pericardial effusion. 
In the latter the dulness is triangular or 
pear-shaped, the base lying below. If the 
effusion is small the lateral area of dulness is 
increased in the upright position over the 
lower part of the precordial region. With 
considerable fluid the extent of dulness is 
most increased vertically, while if the effusion 
is large and is chronic enough to have allowed 
dilatation of the pericardial sac, the transverse 
diameter of the dulness is sometimes enor- 
mously increased. If the pericardium is bound 
to the chest wall by adhesions, the area of 
cardiac dulness may be unchanged and the 
apex remain in the same situation throughout 
respiration. In hypertrophy of the heart, the 
dulness is most marked in its length in hyper- 
trophy of the left ventricle, the apex being 
displaced downward and to the left, while in 
hypertrophy of the right ventricle the increase 
of dulness is greatest laterally. In dilatation 
the area of dulness is increased most markedly 
in the horizontal axis of the heart, to the right 
when the right side is involved, and to the left 



A USCUL TA TIOM. 1 2 3 

when the left side is implicated. Frequently 
dilatation and hypertrophy occur together. 
The area of dulness may be increased by con- 
solidation or contraction of lung over the 
heart. The absence of pleuritic and peri- 
cardial adhesions, or at least their non-inter- 
ference with the free action of the heart and 
the lungs in the neighborhood, may be deter- 
mined by the changes in the position of the 
heart and in the area of superficial dulness 
during respiration. The heart may be pushed 
to either side by pleuritic effusion on the 
opposite side, or drawn to either side or up- 
ward by the contraction of adhesions between 
the pleura and pericardium, or between the 
latter and the chest wall. 

AUSCULTATION. 

From the time of Laennec auscultation 
has been a most valuable aid in diagnosis. 
Without it many morbid changes now clearly 
and sharply defined would be obscure. In 
our day the under-estimation of its value 
need not be apprehended. The tendency 
is rather to neglect other aids to diagnosis 



124 DISEASES OF THE HEART AND LUNGS. 

without which it is often impossible to have 
a just appreciation of conditions that we 
are called upon to treat. Auscultation may 
be practised with the ear or the stethoscope. 
A consideration of both methods, of the stetho- 
scopes to be used, and of other matters apper- 
taining to the subject will be found under the 
head of auscultation of the lungs. 

It seems almost superfluous to say that the 
sounds heard over the healthy heart, their dura- 
tion, quality, pitch, and intensity, should be- 
come thoroughly familiar, and yet the study of 
the organ in health is constantly neglected. 
We should hold firmly to those signs only 
which are fixed exponents of certain conditions, 
and look with suspicion upon doubtful signs 
upon which diagnoses are too often based. 
The correct interpretation of physical signs 
may often be learned from books, but famili- 
arity with the signs themselves can only be 
acquired from the living subject. " To a per- 
son," says Billing, "who has never heard the 
sound of a common gong, describe it until 
he says he thinks he understands it, then let 
him hear it, and he will tell you that it is very 



A USCUL TA TION. 1 25 

unlike what he imagined. Precisely the same 
would happen to any person who should read 
about auscultation before applying his ear to 
a healthy chest." In studying the sounds heard 
over the heart in health and disease, we should 
continually bear in mind that " sound is propa- 
gated according to the same laws, through 
organic as through inorganic matter, through 
living as through dead bodies " (Skoda). And 
by applying these laws, together with the 
results of observation and experience, it is 
seldom, indeed, that we cannot arrive at a 
satisfactory interpretation of physical signs. 

The Sounds of the Heart. — Two sounds 
occur with the movements of the heart. 
The first is prolonged, heavy, and lower- 
pitched than the second, and synchronous 
with the systole of the ventricles, the apex 
beat, and the closure of the auriculo-ven- 
tricular valves, while the second is short, 
sharp, and higher-pitched than the first, and 
synchronous with the diastole of the ventri- 
cles and the closure of the aortic and the 
pulmonary valves. It was one of Broussais' 
pupils who first passed a curved needle through 



126 DISEASES OF THE HEART AND LUNGS. 

a flap of the aortic valve, thus abolishing the 
second sound and at the same time establish- 
ing its cause and the fallacies of a consider- 
able number of theories upon the subject. 
Unfortunately it has not been feasible to 
demonstrate the cause of the first sound in 
the same way, and as a natural consequence 
many theories have arisen. It is generally 
admitted that several elements make up the 
first sound, and that these are mingled in 
varied proportions over different points of the 
cardiac region. Two of these elements are 
the bruit from the muscular contraction of 
the cardiac fibres and the closure of the au- 
riculo-ventricular valves, and another is the 
blow of the apex against the chest wall. The 
friction of the blood against the walls of the 
ventricles and the surfaces of the valves, as 
well as its impact against the blood in the 
aorta with each systole, may be another ele- 
ment. Little attention has been paid to the 
part that the chordae tendineae play in the pro- 
duction of the sound, but, without doubt, it is 
a matter deserving consideration. When the 
auriculo-ventricular valves close, both they 



AUSCULTATION. 12? 

and their chordae tendineae become tense, and 
both take a part in the production of sound. 
It is not improbable that the chordae them- 
seves are the main producers of sound, and 
that the valves act chiefly as diaphragms to 
intensify it. The action of the chordae may 
be perfectly illustrated by alternately loosen- 
ing and tightening a piece of ribbon held be- 
tween the fingers of the two hands. " A short 
piece of ribbon by this sudden tension will 
give out a sharp and distinct sound ; a longer 
one will yield a sound which is more dull and 
prolonged " (Dalton). 

The sounds follow each other in regular 
succession, with a short interval of silence 
between the first and the second, and an inter- 
val about three times as long between the 
second and the first. Both sounds are heard 
over the praecordial region, but vary in differ- 
ent situations. The left side of the heart, on 
account of its greater muscular power, produces 
the largest proportion of the first sound, and 
therefore it is conducted through the chest 
wall with the greatest intensity at the moment, 
and at the point that the apex beat of the left 



128 DISEASES OF THE HEART AND LUNGS. 

ventricle occurs. Passing to the right, over 
the xiphoid appendix, the first sound produced 
by the right side of the heart is heard, shorter 
and higher-pitched than that at the left apex. 
The second sound, produced by the closure of 
the aortic valves, is heard best over the second 
right costal cartilage and its intercostal space. 
The reason of this is that the aorta approaches 
the chest wall in this situation. The sound 
produced by the closing of the pulmonary 
valve may be isolated in the second left inter- 
costal space next to the sternum ; it is lower 
in pitch than the aortic second sound. The 
intensity of the heart sounds and the area over 
which they are heard vary considerably with 
the force of the heart's action, with inspiration 
and expiration, and the conducting power of 
the surrounding media. They are sometimes 
tympanitic in quality in the neighborhood of 
the apex, when the stomach is distended with 
gas and fluid. In patients excited by an ex- 
amination, the first sound often has temporarily 
a high-pitched metallic ring. 

The normal heart sounds are often conveyed 
with abnormal intensity over the chest. In 



A USCUL TA TION. 1 29 

children, owing to the vibratile nature of the 
parietes, they are readily conveyed, and espe- 
cially over the lower part of the left inter- 
scapular region ; and similarly is this the case 
in narrow-chested, thin adults. On the other 
hand, in deformed chests they are often con- 
veyed with diminished intensity. The normal 
heart sounds, when heard over an abnormal 
area, indicate disease of the lungs, pleura, 
or aorta. The lungs, filled as they are with 
air, are poor conductors of vibrations, but 
when compressed, solidified, or bound to the 
chest wall by adhesions, they convey sound 
more readily. Cavities, by acting as resona- 
tors, may increase the intensity of the heart 
sounds, the solidified lung tissue by which they 
are surrounded assisting in the conveyance. 

Either or both sounds of the heart may be 
exaggerated. The first sound at the apex is 
exaggerated, or, more properly speaking, 
changed in quality, becoming sharp, clear, 
high-pitched, and of shorter duration in dila- 
tation of the ventricles. When the dilatation 
is accompanied by marked thinning of the 
walls and tissue degeneration, the first sound 



130 DISEASES OF THE HEART AND LUNGS. 

becomes feeble and ill-defined, as in other 
affections which diminish the force of the 
muscular contraction. In hypertrophy the 
first sound is prolonged and increased in in- 
tensity. It may have a ringing, metallic 
character, and this is sometimes observed in 
health, when the force of the heart's action is 
increased. Thickening of the valves, or de- 
posits on them or on the chordae tendineae or 
pericardial adhesions, may alter the first sound, 
even if the changes have not been sufficient to 
produce murmurs. The second sound over 
the aortic or pulmonary valves may be accen- 
tuated by obstruction to the passage of the 
blood in either artery. In some cases of 
anaemia the aortic second sound is clear and 
distinct. When the edge of the valve is 
thickened, a muffling of the sound is often 
noticed before the changes have been sufficient 
to produce a murmur. 

Intermittence and Irregularity of the Heart. 
— We may have irregularity in the force of 
the cardiac impulse and irregularity in time. 
Intermittence is the simplest form of irregu- 
larity in time. It consists in the omission of 



A USCUL TA TION. 1 3 1 

a pulsation, the next occurring at the usual 
time, and the cardiac rhythm remaining un- 
changed. Instead of one pulsation two or 
three may be omitted, or sometimes one, at 
others two or three pulsations. These inter- 
missions may occur with every second beat or 
at longer intervals. Irregularity in the time 
and force of the cardiac pulsations may happen 
alone or accompanied with intermittence. The 
intervals between the beats are uncertain and 
of varying lengths and the beats themselves 
are of unequal strength. This irregularity 
may have a certain regularity about it — that is, 
the irregularity of one minute may be like the 
irregularity of the previous minute, or there 
may be such a combination of irregular inter- 
missions and unequal pulsations, of forcible 
and feeble beats, as to resemble the changes 
of a kaleidoscope, in which every turn produces 
some new combination. 

Irregularity and intermittence of the heart's 
action, and especially intermittence, are often 
observed in persons having no organic cardiac 
lesion and who enjoy good health. Intermit- 
tence may be merely a constitutional peculi- 



I32 DISEASES OF THE HEART AND LUNGS. 

arity or a purely nervous phenomenon, excited 
by strong emotions, by terror, anxiety, pain, 
or fatigue, and has been known to follow rail- 
way accidents and shipwreck. It may be pro- 
duced by indigestion, and this is a frequent 
cause in children. In such cases it is usually 
temporary and passes away in a few hours or 
days. It is sometimes, however, persistent, 
lasting for weeks or months, or even remaining 
permanently, but the intervals between the in- 
termissions will grow longer. Not infrequently 
iregularity accompanies valvular lesions or 
gout. Intermittence and even irregularity are 
not of themselves necessarily signs of serious 
importance, but with a marked feebleness of 
the impulse, and especially if the contraction 
of the ventricle is ineffectual, they are early 
signs of weakness of the heart, — signs that 
the weakened left ventricle does not react to 
the ordinary stimulus of the blood thrown into 
it by a single contraction of the auricle, but 
waits until a second or even a third contrac- 
tion has supplied it with more blood. In such 
cases it is a sign of valvular disease, more es- 
pecially of mitral regurgitation, with dilatation, 



A USCUL TA TION. I 3 3 

degeneration, and loss of tonicity of the mus- 
cular wall of the ventricle. Intermittence or 
irregularity in the aged, with a feeble and dif- 
fused impulse, and atheromatous vessels, indi- 
cates that an hypertrophied heart has under- 
gone degenerative changes, is unable to recover 
power, and may at any moment cease to act. 
If feebleness of the pulsation has been deter- 
mined by weakness of the pulse, as well as of 
the apex beat, you are far advanced towards 
the diagnosis of degeneration of the heart 
walls. Do not, however, be too hasty in your 
conclusions if the apex beat is feeble or imper- 
ceptible to the touch. Such feebleness may 
be due to an emphysematous lung overlapping 
the heart, to thickness of the chest wall, or 
more rarely to pericardial effusion. Ausculta- 
tion will enable you to fix the exact spot of 
the apex beat, if you fail by palpation. 

In cases of intermittence and irregularity, 
besides being on the lookout for weakness of 
the heart's action, observe the effect of exertion. 
An irregularity merely nervous is scarcely in- 
fluenced by exercise. The pulse is naturally 
quickened, but the irregularity is often dimin- 



134 DISEASES OF THE HEART AND LUNGS. 

ished rather than increased. The irregularity 
due to cardiac disease is notably increased by 
a slight exertion, such as walking briskly. If 
exertion causes the patient distress, notice its 
character. Little or none occurs in irregular- 
ity from nervous causes, while with cardiac dila- 
tation or degeneration the distress is marked. 

The nervous system plays an important 
part in the production of irregularity, whether 
in its slightest or most marked manifestations. 
The ganglia of the heart, which are found 
scattered over its surface as well as through 
the muscular walls, are storehouses of nervous 
energy, and also co-ordinate the cardiac move- 
ments in accordance with the requirements of 
the body. The sympathetic system seems to 
act as an accelerating agency to the ganglia, 
not only increasing the frequency but the 
force of the heart's action. The pneumo- 
gastric, on the other hand, by means of its 
inferior cardiac branch, slows the heart's 
action. The superior cardiac branch, passing 
to the medulla, regulates the movements of 
the arterioles. When, by a rise in the arterial 
tension, the heart is oppressed with work, this 



AUSCULTATION. 1 35 

nerve is thrown into action, and, acting upon 
the arterioles through the medulla, causes their 
dilatation, thus lowering the blood pressure 
and relieving the overburdened heart. 

Paralysis of the Heart. — In some cases 
shock or violent emotion, instead of producing 
irregularity or intermittence, fatally arrests 
the heart's action. This probably never oc- 
curs in perfectly sound persons, but has 
happened so often with those not known to 
labor under any cardiac disease as to make 
it a possible event to any one past middle 
life. The same result may occur in diph- 
theria, cerebro-spinal meningitis, typhus fever, 
and some other diseases. 

Reduplication of the Heart Sounds is a sub- 
ject more interesting than important. Instead 
of a single first sound, we may have two, or 
two second sounds instead of one ; or in its 
rarest form we have four sounds — two first 
and two second. Usually we have reduplica- 
tion of one sound, and reduplication of the 
second is by far the most common. The most 
plausible theory of the cause of reduplication 
of the first sound ascribes it to the non- 



I36 DISEASES OE THE HEART AND LUNGS. 

synchronous contraction of the ventricles. 
Reduplication of the second sound is due 
to the closing of the aortic and pulmonary 
valves at different times. Either valve may 
close first. Reduplication is sometimes a 
symptom of disease when it is often perma- 
nent, but may occur in perfect health, and is 
then usually inconstant, appearing one mo- 
ment and disappearing the next. In fact, 
it is merely an exaggeration of a phenomenon 
which, if carefully sought for, may be de- 
tected in every one : reduplication of the first 
sound occurring at the end of expiration or 
commencement of inspiration ; reduplication 
of the second sound occurring at the end of 
inspiration and the commencement of expira- 
tion. These normal reduplications depend 
upon the variations in pressure produced by 
the respiratory movements at the origin of the 
arterial and venous systems. Reduplication 
of the second sound is frequently associated 
with mitral stenosis and aortic regurgitation. 
In the former it is due to the pulmonary 
congestion always present in these cases, 
which so increases the blood pressure in the 



A USCUL TA TOR Y-PERCUSSION. 1 3 7 

pulmonary artery as usually to accentuate and 
sometimes hasten the closing of the valves 
and so cause the pulmonic to anticipate the 
aortic second sound. 

AUSCULTATORY-PERCUSSION. 

The method of auscultatory-percussion was 
devised by Dr. G. P. Camraann, and the sub- 
ject presented to the profession in a care- 
fully prepared paper by Dr. Cammann and Dr. 
Clark. 1 

Auscultatory-percussion is a combination of 
the methods of auscultation and percussion by 
auscultating the chest with the ear or the 
stethoscope at the same time that percussion 
is practised. Its value hinges upon the fact 
that, if the percussion note of any organ or of 
any part of the body is conveyed to the ear 
through a more or less homogeneous medium, 
the true quality is better appreciated than if it 
be conveyed through air. The value of various 
media for conveying sound differs greatly, but 
need not here be discussed. If it is attempted 
to locate the lower border of the heart by per- 

1 New York Quarterly your, of Med. and Surg., July, 1840. 



I38 DISEASES OF THE HEART AND LUNGS. 

cussion, its accomplishment is difficult for all 
and impossible for many persons. So similar 
are the percussion notes of the liver and heart 
that we are often in doubt as to the line of 
demarkation. But by auscultatory-percussion, 
after a little practice, this line is readily found. 
Thus it may be demonstrated not only that 
each organ has its own percussion note, which 
differs from the percussion note of every other 
organ in health, but also that the percussion 
note of an organ in which morbid changes 
have occurred differs from that of the same 
organ in health. This fact will, I think, 
in the future, lend additional value to aus- 
cultatory-percussion. The method is useful 
in mapping out aneurisms of the aorta, in 
measuring an enlarged spleen when the bor- 
ders of the liver and spleen are in contact, in 
measuring the liver in cases of ascites, in de- 
termining the position of the upper, lower, and 
outer borders of the kidney, and in disclosing 
its absence when that organ is floating, in 
measuring abdominal tumors, and in locating 
the heart in pulmonary emphysema, and in 
pleurisy with effusion, etc. 



A USCUL TA TOR Y-PERCUSSION. 1 39 

In such cases its value is recognized, but I 
would suggest its usefulness also in detecting 
changes from the normal percussion note co- 
incident with morbid changes in the organs 
themselves. In cases of fatty degeneration of 
the heart I have found that by auscultatory- 
percussion the sound conveyed to the ear was 
duller, and had lost the ringing, metallic char- 
acter which distinguishes the normal heart. A 
dilated heart with little or no hypertrophy will 
also give an altered percussion note, but in the 
latter case the difference between the percussion 
notes over the heart and over the lungs is less 
marked than with a fatty heart. The change 
in the percussion note in morbid conditions of 
the liver and kidneys has not been studied 
very fully. The subject has, however, been 
sufficiently investigated to lead me to believe 
that this method may be of value in detecting 
morbid changes in the liver, and possibly in 
the kidneys. 

More attention has been directed to the 
measurement of the heart than to that of any 
other organ. For purposes of comparison it 
is best that all the measurements be made on 



140 DISEASES OF THE HEART AND LUNGS. 

certain fixed lines. The original investigators 
found it most convenient to find eight points 
on the border of the heart at the extremities 
of four diameters. The four diameters are : 

i. The vertical, running to the left of the 
sternum and the root of the aorta. 

2. The transverse, at right angles to the 
above near its centre. 

3. The right oblique, from the right auricle 
to the apex on a line drawn from the right 
shoulder to the apex. 

4. The left oblique, at right angles to the 
last named. 

All the diameters intersect each other at 
one point near the centre of the heart. Be- 
tween these eight points the outline of the 
heart can be readily drawn. 

In the original investigations these points 
were first marked on the cadaver. Sharp- 
pointed steel needles were then inserted, and 
the external parts removed. Usually the 
needles passed between the pericardial sac 
and the heart or just grazed the latter. When 
the right auricle was distended with blood, 
the needle at this extremity of the right 



A USCUL TA TOR Y-PERCUSSION. 1 4 1 

oblique diameter frequently passed from one 
line to half an inch within the border of the 
heart, on account, probably, of coagulated 
blood being a poor conductor of sound, and 
the wall of the auricle being so thin as to have 
little effect on the percussion note. 

Having demonstrated the practicability of 
the method on the cadaver, the heart was next 
measured in the living subject. Here it was 
found that the measurement of the diameters 
in the dead body could not be taken as the 
standard of comparison for the measurement 
of those in the living. The reason is obvious ; 
diastole occupies a longer time than systole, 
and therefore the measurement will usually be 
made during diastole. At this time the cavi- 
ties of the heart are partially or entirely filled 
with blood ; in the cadaver, on the other hand, 
it is rarely that all the cavities are equally 
filled ; one or two may be distended and the 
others empty. It is found, however, that, 
although the diameters taken singly are use- 
less for purposes of comparison, if the sum of 
the diameters be taken they closely correspond. 
The average of the sum of the diameters in 



I42 DISEASES OF THE HEART AND LUNGS. 

the living adult male from the measurements 
of a large number of cases is sixteen and five- 
sixths inches. 

In practising this method, the stethoscope 
should be placed next to the skin, and on that 
part of the chest with which the organ to 
be examined comes in contact. The percus- 
sion should be gentle, moving the percussing 
finger to and fro in the neighborhood of the 
stethoscope. A strong percussion note soon 
fatigues and confuses the ear. Better results 
are attained with than without a pleximeter. 
The osseous sound from the ribs or the 
sternum sometimes is a source of embarrass- 
ment, but may generally be obviated by the 
use of an oval extremity to the stethoscope, 
fitting between the ribs. The ordinary bin- 
aural instrument answers in most cases, or 
the binaural hydrophone or solid cedar stetho- 
scope may be used. 

In comparing the sounds audible by auscul- 
tatory-percussion, we find that the sound heard 
over bone is high-pitched, somewhat prolonged, 
and slightly ringing, and of great intensity, 
striking the ear with even painful force. That 



A USCUL TA TOR Y-PERCUSSION . 



143 



Averages of Sum. 


.5 ~I«Hcq t V-<*- C h' O ^Im'm' 

j O OO CO M M O M 

d »-< u->>d vd vd vd 


Averages of 

Left Oblique 

Diameter. 


.5 0! HT|.!io rH H'"iS 0> H^(M-^ 
J in Oco O O O O M 

ci oi co\j- 4- -3- ^f 4- 
d 


Averages of 

Right Oblique 

Diameter. 


j w co coco co co i~» r-~ 


Averages of 
Transverse Diameter. 


.£ H« O "> H «|t- M H O 
J -3- H CO H O M H M 

.cm' cm" CO CO "j - CO CO CO 


Averages of 
Vertical Diameter. 


13 * h q> q h h h* 
.cm* cm co rj- -f ^ 4 4 


Averages from 

Middle of 

Sternum to Nipple. 


V t-*O.JO 

>J>nH 0>h 1-1 tJ- CO hi 
.CM CM* CO-j-Tt-T}-^-^- 

c 


Averages from 
Second to Sixth Rib. 


.S—lMrfMrnlin 1-1 "~'-*< a> h-i>o|50 hi 

_i co m q q m m 

.coco^j-^t-invn^j-TJ- 


Averages from 
Acromion to Acromion. 


"3 M CO O CM CO O "6>"oo" 

.cd O ^j- in in in <3" ■*}■ 

C HI HI HI HI HI HI HI 


Averages of Stature. 


C 

. co^j-inininininin 


Averages of Age. 


J «|n Jo Hn 
2 O hi rthf. 1 HNlm HI -|M 
COmmOCMvOhic^ 
«' ui d I-*- in -4 'J- co r"- 

£ M HI CM CO TJ- invO 


Number of Cases. £ ?S2>??)?>h 


< 


Years. 
4-7 
7-15 
15-21 
20-30 
30-40 
40-50 
50-60 
60-70 

and 



3 S2 -3 
3 o 2 






5 t) ^ ja 

.a u <u 

^ 3 •£ rQ 



cjO 



S £ t« c 

S * g £ 

2 <S .52 2 



£ < -~ 



E- ?- 1 



144 -DISEASES OF THE HEART AND LUNGS. 

heard over the heart is high-pitched, intense, 
and conducted to the ear with a good deal of 
force, but in a less degree than over bone. It 
gives to the percussion note a sort of metallic 
ring, especially at the circumference. The 
liver produces a lower-pitched, longer, less 
intense note than does the heart. This is 
only by comparison, as the sound is high- 
pitched, of considerable intensity, clear, and 
quite readily conducted. 

By taking the average of the sums of the 
diameters of male hearts, from twenty years 
and upwards, the average of an adult male 
heart is found to be sixteen inches and ten 
lines. 1 

1 Twelve lines equal one inch. 



SECTION V. 



MURMURS. 



A cardiac murmur — that is, a new sound 
occurring with or replacing the heart sounds 
— is produced outside or within the heart 
itself. The former are called exocardial ; the 
latter, endocardial. 

Upon few subjects has more difference of 
opinion prevailed than upon the physical 
causes of cardiac murmurs, and this holds 
true at the present time. A movement in 
the right direction is being made, in the 
endeavor to apply the physical laws of fluids 
and gases, in so far as they touch the con- 
ditions of circulation and respiration, to the 
sounds heard over the chest ; and we may 
be able in the future, with any cardiac mur- 
mur, to recognize the condition of which it is 
the exponent, as easily and certainly as we 
can now, from any given data, demonstrate a 
problem in physics or mathematics. 



I46 DISEASES OF THE HEART AND LUNGS. 

Murmurs are not, as a rule, heard imme- 
diately superficial to their seat of origin — that 
is, the vibrations which give rise to the sounds 
are transmitted from their sources to certain 
areas of the thoracic surface. This transmis- 
sion of sound occurs in two ways : (1) by con- 
duction, when vibrations are conveyed by still 
media or solid structures ; and (2) by convec- 
tion — that is, by media in motion. A murmur 
is heard best in the direction of the current of 
blood leading from its starting-point. This 
may be illustrated by analogy with the air. 
On a still day every thing may be silent ; but 
let a breeze spring up, and the sounds of 
distant bells, for example, are clearly heard. 

PERICARDIAL MURMURS. 

These murmurs are produced by the friction 
of the pericardial surfaces roughened by in- 
flammation and the exudation of plastic mate- 
rial. Pericardial friction has been described 
as a double, to-and-fro sound, corresponding 
to the rubbing of the surfaces together, and is 
both systolic and diastolic. Occasionally the 
sound is single, and then corresponds more 



PERICARDIAL MURMURS. , 1 47 

often with the systole than with the diastole ; 
more rarely it is triple, a rub-a-dub-dub sound. 
The murmur usually is heard best over that 
part of the heart which comes in closest con- 
tact with the chest wall — that is, over the 
lower part of the sternum and the adjacent 
costal cartilages. Often the friction sound is 
limited to the precordial region and even to 
the spot where it is produced ; but if the vibra- 
tions are communicated directly to the sternum 
they may be quite widely distributed, the 
sternum acting as a sounding-board. It is not 
conveyed away from the orifices and along 
the great vessels, as is an endocardial murmur. 
Although usually harsh, it may be soft in 
character, and is commonly superficial, seem- 
ing to be produced directly under the ear, 
and is altered by change of position, or by 
the pressure of the stethoscope over the seat 
of its production. Not strictly synchronous 
with the heart sounds, it varies in character, 
position, and intensity from moment to mo- 
ment. 

A difficulty may arise in deciding whether 
the murmur is pericardial or pleural, or peri- 



I48 DISEASES OF THE HEART AND LUNGS. 

cardial-pleural, and in some cases we may not 
be able to determine. When heard over the 
left border of the heart and not over the 
sternum, and completely, or almost, arrested 
by holding the breath, it is pretty certainly 
pleural, but it may be pleural and still con- 
tinue with the movements of the heart after 
the breath is held. A loud pericardial mur- 
mur may almost obscure, but does not alter, 
the heart sounds. 

VALVULAR MURMURS. 

Murmurs may be produced at any of the 
cardiac orifices, but in the great majority of 
cases originate at the aortic or mitral, mur- 
murs of the right side of the heart being com- 
paratively rare. They are generated either 
by the blood in its natural onward course, or 
by its passage backward through imperfect 
closure of the valve. 

The theory that murmurs are due to fric- 
tion of the blood current on the containing 
walls, and the throwing of these walls into 
vibration at the seat of production, has been 
rendered by recent investigations more than 




.FIGURE 17. 

DIAGRAMMATIC REPRESENTATION OF SYSTOLIC AND DIASTOLIC 
MURMURS. (BRAMWELL.) I AND 2 REPRESENT THE LENGTH OF 
THE HEART SOUNDS ; A AND B THE PERIODS OF SILENCE ; HORI- 
ZONTAL LINES THE HEART-SOUNDS ; VERTICAL LINES THE MUR- 
MURS. 




Figure 18. 
diagrammatic representation of systolic and presystolic 
murmurs. (bramwell.) 




Figure 19. 

diagrammatic representation of systolic, diastolic, 
presystolic murmurs. (bramwell.) 

149 



150 DISEASES OF THE HEART AND LUNGS. 

doubtful. Savart demonstrated that a liquid, 
when it flows from a reservoir through an ori- 
fice assumes the form of a jet, to which he 
gave the name of " fluid vein." The first part 
of the stream is transparent and stem-like ; 
farther on it is divided into elongated swel- 
lings separated by narrow portions. This 
nodal appearance shows that the liquid vi- 
brates. On more minute examination the 
stream is found to consist of separate drops 
succeeding each other at regular intervals, 
and changing their form as they go, so that in 
the narrow portions the long axis of the drop 
is the same as the axis of the stream, and in 
the wider parts the long axis of the drop is at 
right angles to the stream. It is asserted that 
the vibrations of this stream produce the 
murmur. 

Heynsius gives another explanation, that 
murmurs are produced by eddies when the 
stream passes from a narrow to a wider tube. 
The production of these eddies can be easily 
understood by watching a narrow stream 
flowing into a pond. The stream rushes in, 
spreading out as it goes, and the water at 



VALVULAR MURMURS. I$I 

each side near the point of entrance is thrown 
into eddies and drawn into the current, but is 
replaced by the water farther along returning 
with a rotatory motion. 

Rhythm. — By the rhythm of a murmur is 
meant the relationship which it bears to the 
sounds and silences of the heart. When the 
heart is beating rapidly it is often difficult 
and sometimes impossible to tell exactly the 
time at which the murmur occurs. We may 
be able to do so by comparing the time with 
reference to the pulse. 

The Direction in which the Murmur is 
Propagated. — A murmur is propagated in a 
definite direction through the solid tissues in 
the neighborhood, and carried along by the 
current of blood in which it is generated. 

Pitch, Quality, Intensity, and Duration. — 
These are governed by acoustic laws, but 
are not of as much practical importance as 
might at first be supposed. When we remem- 
ber that the character of the sound is chiefly 
due to the force of the blood current, and that 
the heart acts more forcibly at one time than 
at another, this will be readily recognized. 



152 DISEASES OF THE HEART AND LUNGS. 

Murmurs differ much in character. Some are 
soft and blowing ; others harsh, grating, rasp- 
ing, filing, or sawing. Valvular murmurs 
modify and sometimes completely replace the 
heart sounds. 

AORTIC OBSTRUCTION. 

This is due to interference with the outflow 
of blood through the aortic orifice. It is sys- 
tolic in time, heard with the greatest intensity 
over the second right costal cartilage, and 
transmitted with decreasing intensity along 
the aorta and the carotids. It may be trans- 
mitted towards the apex and heard behind to 
either side of the spine on a level with the 
second, third, and fourth dorsal vertebrae. If 
the murmur be musical and penetrating (as 
may occur in those exceptional cases in which 
a shred of lymph adheres to the valves), it is 
occasionally heard over the lower end of the 
sternum and behind as low as the sacrum. It is 
sometimes loudest at mid-sternum, opposite the 
third interspace, or to the left of the sternum. 

AORTIC REGURGITATION. 

This murmur is diastolic in time, occurs 
with the second sound of the heart, and is due 



MITRAL REGURGITATION. I 53 

to the back flow of blood through the aortic 
orifice. Usually it is heard with greatest in- 
tensity over the third and fourth left costal 
cartilages. It may be loudest over the sternum, 
and transmitted towards the apex and xiphoid 
appendix, upward and to the right, and be- 
hind to the left of the spine and the angle of 
the scapula. If the murmur is heard with 
some of the clicking sound due to closure of 
the valves— that is, if it accompanies and does 
not replace the second sound, it is evident that 
all the segments of the valve are not involved. 1 

MITRAL REGURGITATION. 

This murmur is due to the back flow of 
blood through the mitral orifice, is systolic in 
time, heard at the apex, and transmitted to 
the left, and is heard to the left of the spine 
from the fifth to the eighth dorsal vertebra. 

1 When an aortic regurgitant murmur is conducted to the apex, " it 
depends on the regurgitation taking place through incompetency of 
the posterior aortic segment. I believe that we may also say that a 
similar murmur propagated towards the ensiform cartilage indicates 
incompetency of either the left or the right coronary segment." — Dr. 
B. Foster, as quoted by Sansom. It is probable that conduction to 
the apex depends upon the force of the heart's action and the subse- 
quent recoil. 



154 DISEASES OF THE HEART AND LUNGS. 

According to Balfour, this murmur is some- 
times heard at the left base, being there 
conducted through a dilated left auricular 
appendix. 

MITRAL OBSTRUCTION. 

This murmur is due to interference with 
the flow of blood through the mitral orifice. 
It is presystolic in time — that is, it commences 
during the diastole of the heart and ends with 
the systole, and is heard with greatest inten- 
sity at the apex. Sometimes it is loudest just 
internal to, or above, the apex. 

This murmur is generally accepted as evi- 
dence of mitral stenosis, and certainly occurs 
with that lesion. That it is a positive sign 
of that condition, however, may be doubted. 
Cases are recorded in which this murmur was 
heard and no stenosis of the mitral valve 
found post mortem, and a large number of 
cases are reported in which with marked ste- 
nosis no murmur occurred. 

PULMONARY SYSTOLIC MURMUR. 

This murmur is heard to the left of the 
sternum in the- second interspace, and occa- 
sionally over the third costal cartilage. It is 



PULMONARY REGURGITANT MURMURS.. I 55 

systolic in time, and not widely transmitted, 
being conveyed upward and to the left. 

The cause of this murmur has produced 
much controversy, and is not yet satisfactorily 
determined. It has been variously asserted to 
be due to mitral regurgitation ; dilatation of 
the pulmonary artery ; compression of the 
artery by a dilated left auricular appendix, 
by consolidated lung, or by morbid growths 
within the thorax ; the better conveyance of 
the first sound and its harmonics by consoli- 
dation or adhesions. It is pretty generally 
accepted that it is of pulmonary origin, and 
usually depends upon an altered condition of 
the blood. Stenosis of the pulmonary orifice 
occasionally occurs, and is the cause of the 
murmur, but such cases are extremely rare. 
An anaemic murmur is sometimes heard at 
the same time with an aortic anaemic murmur. 

PULMONARY REGURGITANT MURMURS. 

These murmurs are so rare that they may 
be practically ignored. They would be heard 
over the heart on the left side, and conveyed 
down toward the lower part of the sternum. 



156 DISEASES OF THE HEART AND LUNGS. 
TRICUSPID REGURGITATION. 

This murmur is due to the back flow of 
blood through the tricuspid orifice, is systolic 
in time, with its point of maximum intensity 
at the lower end of the sternum. It is not 
widely propagated. 

TRICUSPID OBSTRUCTION. 

If murmurs exist from contraction of the 
tricuspid orifice they are extremely rare, or 
probably are never heard. 

INTRAVENTRICULAR MURMUR. 

This murmur is produced within the ven- 
tricles, and is not of valvular origin. It is 
systolic in time, may be soft and blowing, or 
loud and harsh, and is more frequently pro- 
duced in the left than in the right ventricle. 
When generated in the left ventricle it is 
heard with greatest intensity at the apex, but 
may be widely diffused, and occur also at the 
base and around the chest to the angle of the 
left scapula, or to the right toward the ster- 
num. It may modify the aortic obstructive, 
and mitral regurgitant murmurs, and is some- 



COMBINATION OF MURMURS. I 57 

times heard to the left of the spine over the 
seat of the latter, but in this case it is dif- 
fused, not very loud, and has not a point of 
greatest intensity. 

An intraventricular murmur of the right 
side is heard ordinarily with the greatest in- 
tensity over the lower part of the sternum, or 
by its left side, but may be transmitted up- 
wards to the left clavicle. It is not usually 
so loud as that produced on the left side. 

AN.-EMIC MURMUR. 

This murmur is always systolic, occurs over 
the base of the heart, usually over the aortic 
area, less commonly over the pulmonary, is 
soft and blowing in character, and heard usu- 
ally along the course of the great vessels, 
where slight increase of pressure with the 
stethoscope will increase its intensity. It oc- 
curs in conditions of anaemia, and will usually 
disappear under proper treatment. 

COMBINATION OF MURMURS. 

Frequently two or more murmurs occur at 
the same time, and run into one another in 



158 DISEASES OF THE HEART AND LUNGS. 

such a way that we can distinguish with diffi- 
culty what murmurs are really heard, and this 
is more especially so in a rapid, irregular, 
and weak heart. The two murmurs most com- 
monly occurring together are aortic obstructive 
and regurgitant, and later a mitral regurgitant 
is apt to be added. Mitral obstruction and 
mitral regurgitation often occur together, and 
tricuspid regurgitation frequently follows mitral 
lesions. Probably the tricuspid murmur is 
often obscured by the louder murmurs of the 
left side of the heart. We may also have a 
pericardial or pleural murmur added to those 
of endocardial origin. The sounds of the heart 
may be replaced by murmurs, or the sounds 
may remain but be more or less obscured. 

VARIABILITY OF MURMURS. 

There is scarcely a murmur that may not 
vary in character or disappear. This may 
result from a disappearance of the causative 
lesion, or from a change in other conditions, 
the lesion remaining the same or actually in- 
creasing. The mitral obstructive is the most 
variable murmur. In a large proportion of 



VARIABILITY OF MURMURS. 1 59 

cases no murmur is appreciable, and in others 
it is heard and then vanishes. A frequent 
cause of the lessened intensity or disappear- 
ance of a murmur is the patient being at rest, 
the murmur reappearing when he moves. A 
change in the character of an aortic murmur 
is common, but its disappearance not so fre- 
quent. Both the tricuspid and mitral re- 
gurgitant murmurs may disappear and again 
reappear. 

Bearing these facts in mind, we recognize 
that the absence of murmur does not always 
denote the absence of valvular lesions. Nor 
does the presence of a murmur necessarily 
indicate the presence of valvular disease, nor 
of an incurable cardiac lesion ; nor is the 
intensity of a murmur an index to the gravity 
of the condition. 



SECTION VI. 

PERICARDITIS. 

Inspection. — The effusion may be sufficient 
to cause bulging of the chest and widening of 
the intercostal spaces over the precordial re- 
gion. This is rarely the case, however, except 
in children with yielding chest walls. 

Palpation. — When effusion has taken place 
the apex beat is displaced upward and to the 
left, and, with considerable effusion, is feeble 
and irregular, or more rarely completely 
effaced. 

Percussion. — With effusion the area of dul- 
ness is increased. With moderate effusion the 
enlargement is most laterally, over the lower 
part of the precordial region when the patient 
is in the upright position. With still larger 
effusion the area of dulness increases verti- 
cally, and is pyramidal in form, with the apex 
above. With very large effusion the area of 
1 60 




Figure 20. 

pericardium containing fifteen ounces 

of fluid. (sibson.) 

" I6l 



Figure 21. 

pericardium containing £ pound 

of fluid. (sibson.) 



1 62 DISEASES OF THE HEART AND LUNGS. 

dulness is enormously increased. In some 
cases we can distinguish the outline of the 
pericardium from the outline of the heart. 

Auscultation. — Early in the disease a fric- 
tion murmur, due to rubbing together of the 
two pericardial surfaces, may be present, and 
closely resemble an endocardial murmur. From 
the latter it is distinguished by being super- 
ficial, not strictly synchronous with the heart 
sounds, and varying in character, position, and 
intensity from hour to hour. It has been 
more fully considered under the head of 
murmurs. 

Crackling sounds, fine or coarse in charac- 
ter, due to plastic exudation, becoming coarser 
as the exudation becomes older, and limited 
to the prsecordial region, may now and then 
be heard. In some cases of pericarditis the 
effusion is so small as not to be detected, but 
in others it comes on rapidly, and the friction 
murmur and crackling disappear or are heard 
only at the base of the heart near the great 
vessels. The cardiac sounds at first are forci- 
ble, but with increasing effusion become feeble 
or irregular or absent. The area occupied by 



ADHERENT PERICARDIUM. 1 63 

the distended pericardium can be determined 
by the voice, as at the border of the area 
the vocal resonance is suppressed or greatly 
diminished. 

ADHERENT PERICARDIUM. 

Instead of the pericardium returning to its 
normal condition after pericarditis, adhesions 
may remain permanently. Adhesions between 
the two surfaces of the pericardium, even when 
extensive, are often difficult or impossible to 
recognize. With adhesions between the ex- 
ternal surface of the pericardium and the chest 
wall or the lungs, the diagnosis is not always 
so difficult. 

Inspection. — A retraction is noticed in some 
cases of the intercostal spaces and even of the 
lower half of the sternum with each systole, 
and a springing forward again during diastole. 
If this sign is still present when the patient 
has taken a deep inspiration, the diagnosis is 
still more probable. 

Palpation. — The impulse may be diffused 
and split up, as it were, into several parts. The 
position of the apex beat may remain un- 



164 DISEASES OF THE HEART AND LUNGS'. 

changed by respiration and by change in the 
position of the patient. The heart may be 
displaced, usually upward to the right or left. 

Percussion. — When the pericardium is ex- 
tensively adherent to the chest wall, the area 
of superficial dulness is unchanged by respira- 
tion. 

Auscultation. — A friction murmur or crack- 
ling sounds, fine, coarse, or creaking, may be 
heard with the movements of the heart. 

HYDROPERICARDIUM. 

Fluid in the pericardium, if in sufficient 
quantity, increases the area of precordial dul- 
ness. No friction sounds are present. It is 
not uncommonly one of the signs of general 
dropsy, and is often difficult to detect. 

HYPERTROPHY. 

Inspection. — The area of visible impulse is 
increased often enormously. In some cases, 
more especially in children, the precordial 
region is distinctly prominent. If the heart 
be extensively covered by lung, considerable 
care may be required to recognize the hyper- 
trophy. 



DILATATION. 1 65 

Palpation. — The apex beat is forcible and 
heaving in character. In hypertrophy of the 
left ventricle it is displaced to the left and 
downwards ; if the right ventricle is enlarged, 
the displacement is to the right. 

Percussion. — The area of cardiac dulness is 
increased, the increase being most marked in 
its length in hypertrophy of the left, and in 
its breadth in hypertrophy of the right, ven- 
tricle. 

Auscultation. — The first sound is muffled, 
prolonged, and may be considerably increased 
in intensity. The second sound is increased 
in intensity. 

DILATATION. 

Inspection. — The visible area of the apex 
beat is increased and more diffused than in 
hypertrophy. 

Palpation. — The apex beat is short, diffused, 
and feeble, and may be displaced downward 
and to either side. 

Percussion. — The area of dulness is increased 
most markedly in the horizontal axis of the 
heart, to the right or left, corresponding to the 



1 66 DISEASES OF THE HEART AND LUNGS. 

side involved. The increase is less extended 
downward. 

Auscultation. — The first sound is short, and, 
if the walls are thin, has a high-pitched, clear, 
and ringing character. If the muscular tissue 
be at all disorganized, it is feeble. The second 
sound may or may not be heard at the apex. 

Hypertrophy and dilatation commonly occur 
together. 

FATTY DEGENERATION AND INFILTRATION. 

The physical signs of fatty degeneration 
and infiltration are negative rather than posi- 
tive, and denote the absence of power. They 
are in many respects the same as those of 
dilatation. 

Inspection. — Feebleness or absence of im- 
pulse. 

Palpation. — The apex beat is feeble and in- 
distinct or totally wanting. 

Percussion. — The area of dulness remains un- 
changed, unless altered by some other cause. 

Auscultation. — The first sound is short and 
feeble. The second sound is feeble. The 
heart's action is often irregular. 



ANEURISM OF THE THORACIC AORTA. 1 67 

Auscultatory-Percussion. — With consider- 
able fatty degeneration the percussion note 
loses its high-pitched, metallic character, and 
is lower-pitched, deadened, and less intense. 

ANEURISM OF THE THORACIC AORTA. 

Many cases of aortic aneurism are obscure 
in their early manifestations, and later admit of 
an easy diagnosis ; others are obscure through- 
out, and may not allow us to make a positive 
diagnosis during life. As long as the aneurism 
remains enclosed within the chest without 
touching the surface we cannot make a diag- 
nosis from the physical signs. The largest 
percentage of aneurisms are of the ascending 
aorta,and the percentage becomes smaller as we 
pass farther from the heart. The cause of this 
is mechanical, the pressure of the blood in the 
artery being greater the nearer it is to the heart. 

Aneurisms are of various shapes. The cali- 
bre of the artery may be evenly enlarged, or 
in addition there maybe local bulgings, or the 
bulgings may occur alone. We also have dis- 
secting aneurisms in which the blood burrows 
between the coats of the artery. 



l68 DISEASES OF THE HEART AND LUNGS. 

Inspection. — Early in the disease inspection 
shows no evidences of aneurism. Later a 
bulging and pulsation are seen to the right of 
the sternum at the second interspace, if the 
ascending portion of the arch is involved ; over 
the upper part of the sternum and the epister- 
nal notch, with aneurism of the transverse part ; 
and usually to the left of the sternum, when 
the descending portion of the arch is impli- 
cated. The extent of the bulg-ino- varies, and 
may reach several inches to the right of the 
sternum and downward, or to the same extent 
on the left side. The upper portion of the 
sternum may be pressed forward, and the epi- 
sternal notch filled, and parts of the sternum, 
cartilages, ribs, and vertebrae eroded. A pul- 
sation will be seen, usually double, unless the 
aneurism contains a fibrinous clot, when no 
pulsation may be visible. Pulsation is best 
detected by looking across the bulging. If 
the aneurism is from the inner aspect of the 
ascending or transverse arch, no bulging may 
appear externally. In aneurism of the de- 
scending aorta bulging may or may not be ob- 
served to the left of the spine. Cyanosis of 



ANEURISM OF THE THORACIC AORTA. 1 69 

the head, neck, and upper extremities indi- 
cates pressure upon the superior vena cava ; 
and if confined to the right side, pressure upon 
the innominate vein. 

Palpation. — Pulsation may be felt in the 
same situations as the bulging is seen, the 
pulsation sometimes being perceptible to the 
touch before any bulging is visible. The pul- 
sations are usually more forcible than those of 
the heart, and expansion takes place in every 
direction. The pulsations may be equally for- 
cible with, or less so than, those of the heart, 
and this would be the case if the aneurism was 
lined with fibrin. Pulsation may be absent, as, 
for example, when the sac is filled with fibrin, 
with only a small opening through for the pas- 
sage of the blood. By palpation, we may esti- 
mate the size and density of the aneurism ; and 
by diminution of expansion over one side and 
the feebleness or absence of vocal fremitus, 
whether the aneurism presses to any consider- 
able extent upon the lung or air passages. 
The pulse of the carotids and the radial arte- 
ries may be unequal on the two sides, from 
pressure or obstruction due to the aneurism. 



170 DISEASES OF THE HEART AND LUNGS. 

The heart may be displaced downward and to 
one side or the other. A thrill may be felt. 

Percussion. — When the aneurism reaches the 
walls of the chest circumscribed dulness is ob- 
served at that point, the aneurism always being 
larger than the area of greatest dulness on ac- 
count of its more or less globular shape. The 
consistence of the tumor may be estimated by 
the sense of resistance. Consolidated or com- 
pressed lung in the neighborhood increases 
the area of dulness, while emphysematous 
lung decreases it. 

Auscztltatory-Percussion. — The size of the 
aneurism can be best estimated by auscultatory- 
percussion, and it has the advantage of requir- 
ing only gentle percussion even for deep-seated 
parts. If the aneurism touch the chest wall at 
any point, we should place the stethoscope over 
it and percuss around. By this means the out- 
line can be determined with accuracy. If the 
ascending aorta is involved, dulness occurs on 
the right side of the sternum at the second 
and third interspaces. Sometimes an aneu- 
rism of the anterior portion extends to the 
left, and is then more difficult to discover. An 



ANEURISM OF THE THORACIC AORTA. .171 

aneurism of the transverse portion of the arch 
gives dulness over the upper part of the ster- 
num ; and of the descending portion, to the 
left of the sternum and behind to the left of 
the spine and more rarely to the right. The 
area of dulness may be much extended with 
increase in the size of the aneurism. Consoli- 
dated or compressed lung increases the area 
of dulness, but the difference between the per- 
cussion note and that of the aneurism can be 
recognized by auscultatory-percussion. By 
having an assistant percuss gently over the 
aneurism in front and placing the ear or the 
stethoscope on the chest behind, or vice versa, 
and by moving one or the other from place to 
place, we can make a more accurate estimate of 
the size, shape, and position than by any other 
means. By auscultating over the point of 
greatest dulness in front, and moving the per- 
cussing finger over the back and marking out 
the area of dulness, and then reversing this 
and auscultating behind while percussing in 
front, we can form a pretty good idea of 
whether the aneurism touches both the ante- 
rior and posterior chest wall, and if not how 



172 DISEASES OF THE HEART AND LUNGS. 

near it approaches either, whether it invades 
both sides of the chest, and whether its shape 
is regular or irregular, and which of its dimen- 
sions is the greater. The presence of consoli- 
dated or compressed lung or of fluid in the 
pleural cavity may interfere with the demon- 
stration of all these points. 

Auscultation. — The sounds heard over 
aneurisms and their character depend upon 
the position of the aneurism, the shape, the 
condition of the contents, the character of the 
orifice, and the force of the heart's action. In 
some cases, even over very large aneurisms, 
no sounds are heard. Usually sounds or mur- 
murs are present louder, sometimes as loud, 
at others less loud, than those of the heart. 
There may be simply a jog or shock, either 
single and systolic in time, or double, both 
systolic and diastolic. In other cases mur- 
murs are heard, single or double, varying in 
character, frequently louder than any heart 
murmur. When two murmurs occur at the 
base of the heart, the same murmurs intensi- 
fied are heard over the tumor. The aneu- 
rismal sounds or murmurs are of greatest 



VENO US M URM URS. 1 7 3 

intensity where the aneurism most nearly 
approaches the chest wall — that is, over the 
seat of the greatest dulness. When the tumor 
presses on a large bronchus so that little or 
no air enters the lung, the breath and voice 
sounds are feeble or suppressed. If pressure 
upon the bronchus does not prevent the free 
passage of air, the breathing may be stridu- 
lus. By changing the position of the patient 
and causing him to lean forward or to one 
side, the pressure may sometimes be removed, 
the air be heard to enter the lung more 
freely, and assistance thus gained in deciding 
the exact position of the tumor. When the 
lung is compressed we have bronchial breath- 
ing. 

VENOUS MURMURS, CONGESTION, AND PULSATION. 

On auscultating over the internal jugular 
vein just above the clavicle, a continuous hum- 
ming murmur is often audible. This is heard 
even in some healthy persons, but most com- 
monly in the anaemic. It is the bruit de 
diable of French authors, and may be soft or 
loud and hissing, and now and then has a 



174 DISEASES OF THE HEART AND LUNGS. 

peculiar singing character. Interrupted ve- 
nous murmurs are rare. 

With failure of the right heart to act prop- 
erly we have venous congestion and dilatation. 
With tricuspid regurgitation occurs pulsation 
of the veins of the neck, and this may happen 
even without the presence of the murmur. A 
pulsation may also be observed over the liver. 
Venous fulness occurs either from causes act- 
ing temporarily, or from lesions of the right 
side of the heart, or from pressure of a tumor 
interfering with the circulation. 

THE PULSE. 

The study of the pulse is often useful. In 
referring to the pulse, we mean that of the 
radial artery at the wrist. The pulse, how- 
ever, may be felt over the other superficial 
arteries. 

It should be studied with reference to the 
frequency, rhythm, volume, tension, and to 
any special characters which each pulse may 
possess. The average normal rate in the 
adult male in a state of rest is 72, but in some 
persons it is habitually as high as 100, and in 



THE PULSE. 175 

others as low as 50. Children with a slow 
pulse are apt to have some form of cerebral 
disturbance. The pulse is quicker in children 
than in adults, slightly quickens in old age, 
and is quicker in women than in men. In 
nervous persons the mere presence of the 
doctor may increase the pulse 10 to 40 beats. 
Marked alterations in the pulse may occur 
without the presence of cardiac lesions. A 
functional disorder has been noticed by Flint, 
in which a strong ventricular systole alternated 
with one too weak to produce a radial pulse, 
thus while the heart beats were 70 the radial 
pulse was 35 a minute. 

In advanced cases of fatty infiltration and 
degeneration of the heart the pulse is small, 
weak, and irregular, and maybe rapid or slow. 
In dilatation it is "usually weak, small, rapid, 
and may be irregular and intermittent. The 
frequency of the " pulse is often less than of 
the cardiac pulsations, on account of many of 
the pulse waves being too feeble to reach the 
wrists. In hypertrophy the pulse is full and 
strong. 

In mitral regurgitation the volume and ten- 



I76 DISEASES OF THE HEART AND LUNGS. 

sion of the pulse are diminished, the extent of 
the diminution depending upon the extent of 
the lesion and the condition of the left ventri- 
cle. The pulse may be so small as barely to 
be perceptible, or it may be scarcely modified 
from the normal. 

With marked mitral stenosis the pulse is 
small, and with failure of the heart muscle 
becomes quick and irregular. 

In aortic regurgitation the pulse is quick, 
jerking, and collapsing in character. It is 
usually made more prominent by raising the 
arm above the head, but if the heart is acting 
feebly such is not the case. It is called the 
water-hammer or Corrigan's pulse. 

In aortic stenosis the volume is diminished, 
but the tension is good, and it is apt to be 
slower than normal. Hypertrophy of the 
heart strengthens the pulse. 

THE SPHYGMOGRAPH. 

The sphygmograph is not much used in 
private practice in this country. As with the 
instruments at present in use we cannot be 
sure that the pressure is always the same, its 



THE SPHYGMOGRAPH. 



177 



chief value is in recording the frequency and 
regularity or irregularity of the pulse. It is 
useful for teaching, or the recording of cases. 
The finder is of more Value in the great 



9— ■- — 




Figure 22. 
dudgeon's sphygmograph. 



majority of cases. Marey's sphygmograph, 
Mahomed's modification of the same, or Dud- 
geon's or Pond's instruments may be used. 
Dudgeon's is the most convenient. 






I78 DISEASES OE THE HEART AND LUNGS. 

The healthy pulse consists of a slightly 
oblique line of ascent, a summit, and a broken 
line of descent. The first break in the line of 
descent is the true pulse wave, the summit 
being separated from it by the action of the 
instrument. The next secondary wave is 
called the dicrotism, and is the result of the 
rebound of the blood column from the closure 
of the aortic valves. Other slight undulations 
are sometimes seen in the line of descent. 

THE END. 



INDEX. 



PAGE 

Accentuation of Heart Sounds ...... 130 

Acoustics of Chest ........ 31 

Adhesions, Pericardial ....... 163 

" Pleural . . ' 56, 72, 85 

Adventitious Sounds ........ 57 

^Egophony. ......... 51 

Amphoric Breathing ........ 48 

" Resonance ........ 43 

" Voice 52 

Anaemic Murmur . . . . . . . . 157 

Analysis of Respiration ....... 37 

" of Sounds ........ 32 

Aorta, Aneurism of ....... . 167 

" Dulness from ........ 121 

" Position of 6, 108 

Aortic Obstruction ........ 152 

" Regurgitation . . . . . . . . 152 

Apex Beat, Character of . . . . . . . 116, 117 

" " Position of ...... 104 

Apoplexy, Pulmonary ....... 97 

Asthma .......... 79 

Atelectasis .......... 96 

Auricles, Position of ....... . 106 

Auscultation ........ 21 

" in Disease ....... 44 

" of Heart 123 

Auscultatory-Percussion ....... 137 

179 



i8o 



INDEX. 



Axillary Region . 
Bacillus of Tuberculosis 
Bifurcation of Trachea 
Borborygmi, Sounds from 
Breathing, Rapid, Causes of 
Bronchial Breathin^ 

;e of 
'• . Rales. 
" Whisper 

Bronchiectasis 
Bronchitis, Acute 

" Capillary 

" Chronic 

Bronchophony . 
Bruit de Diable . 
Bulging of Chest 
Cancer, Pulmonary 
Cardiac Area, Deep-Seated 

" " Superficial 

Cardiac Murmurs 

" Combination of 

" Variability of , 

Carotid Arteries, Position of 
Catarrhal Pneumonia, see Lobular Pneumonia. 
Cavernous Respiration 
Cavities, Position of Opening 
" Signs of 

" Size, Form, and Condition of 

Cerebral Disease, Effect on Respiration 
Chest, Acoustics of . 
" Contraction of 
" Movements of 
" Regions of 
" Shape of . 
Chest-Wall, Sounds in 



INDEX. ] 8 T 

PAGE 

Cheyne-Stokes' Respiration ...... 49 

Clavicular Region ........ 2 

Click, Metallic 54 

Coarse Rales 54 

Cogged-Wheel Respiration ...... 47 

Collapse, pulmonary ........ 96 

Compression of Lung 74 

Congestion, Pulmonary ....... 83 

" Venous ........ 173 

Consonance .'....... 35 

Corrigan's Pulse . . . . . . . . . 176 

Cough, in Health ........ 39 

" in Disease ........ 52 

" with Cavities . . . . . . . . 94 

Cracked-Pot Sound ......... 43, 90 

Creaking, Bronchial ........ 56 

" Pleuritic ........ 55 

Crepitant Rales .......... 53 

Croupous Pneumonia, see Lobar Pneumonia. 

Cyanosis from Aneurism ....... 168 

Degeneration, Fatty, of the Heart . . . . • . 166 

Depression under Clavicles ...... 85 

Diastolic Murmur, see Mitral Stenosis and Aortic Regurgi- 
tation. 

Dicrotism of Pulse . . . . . . . . 178 

Dilatation of Bronchi ....'... 67 

" of the Heart ....... 165 

Diminished Vocal Resonance ...... 50 

Displacement of Heart ....... 123 

Divided Respiration ........ 47 

Dry Pleurisy 71 

Dulness .......... 18 

" in Disease ........ 42 

" in Health ......... 20 

" Meaning of Term ........ 18 



1 82 INDEX. 



PAGE 

Duration of Sound ........ 32 

Echo 36 

Elements of Sound 32 

Emphysema, Pulmonary ....... 78 

Empyema 75 

Endocardial Murmurs ....... 145 

Epigastrium, Pulsation in . . . . . . . 117 

Exaggerated Pulmonary Resonance ..... 42 

Vocal Resonance ...... 50 

" Heart Sounds 129 

Exocardial Murmurs ........ 145 

Expansion and Bulging of Chest . . . . . 11 

Expiration .......... 37 

" Prolonged ....... 46 

Fatty Heart . . . 166 

Feeble Respiration ........ 46 

Fibrinous Pleurisy ........ 71 

Fibroid Phthisis 83 

Flatness 19 

" in Disease . 42 

Fluid Vein of Savart . 150 

Forced Respirations 38 

Forcible Percussion 17 

Fremitus, Cause of . . . • . . . . 40 

" Normal Vocal t 13 

" in Disease ........ 52 

Frequency of Pulse 174 

" of Respiration ....... 10 

Friction, Pericardial ........ 146 

" Pleuritic 55 

Gangrene, Pulmonary ...... 98 

Gurgling Rales . 54 

Hair, Rales from . 57 

Harsh Respiration ........ 45 

Healthy Chest, Form of 9 



INDEX 










183 


PAGE 


Haemoptysis ......... 81 


Heart, Sounds of 










125 


" Auscultation of 










123 


" Auscultatory-Percussion of 










137 


" Inspection of . 










"5 


" Intermittence and Irregularity 


of 








130 


" Murmurs, Anoemic . 










157 


" Aortic Obstructive 










152 


" Aortic Regurgitant 










152 


" Combination of 










157 


" Intraventricular 










156 


" " Mitral Obstructive 










154 


" Mitral Regurgitant 










153 


" " Pulmonary Regurgitant 








155 


" Pulmonary Systolic. 








154 


" Tricuspid Obstructive 








156 


" Tricuspid Regurgitant 








156 


" Valvular. 








148 


" " Variability of 












158 


" Palpation of . 












117 


" Percussion of . 












118 


Heynsius, Theory of Murmurs 












150 


Hydropericardium 












164 


Hydrophone 












27 


Binaural 












28 


Hydropneumothorax . 












76 


Hydrothorax 












75 


Hypertrophy of Heart 












164 


Immediate Auscultation 












21 


" Percussion 












17 


Infarction, Pulmonary 












97 


Inflection of Sound . 












121 


Infra-Axillary Region 












3 


Infra-Clavicular Region 












2 


Infra-Mammary Region 












3 



1 84 INDEX. 

PAGE 

Infra-Scapular Region ....... 4 

Innominate Artery, Position of . . . ■ . . . 6 

Inspection g 

" of Heart ........ 115 

Inspiration ......... 37 

Intensity of Sounds 32 

" " " of Heart 151 

Intermittence of Heart . . . • . . . 130 

Interrupted Respiration ........ 47 

Interscapular Region ........ 4 

Intra-Pleural Rales 54 

Intra-Ventricular Murmur . . . . . . . 156 

Irregularity of Heart ........ 130 

Jugular Veins, Murmur over ...... 173 

" " Pulsation of 173 

Lobar Pneumonia 68 

Lobular Pneumonia ........ 70 

Lower Sternal Region ....... 3 

Mammary Region ........ 3 

Mechanism of Heart Sounds ...... 125 

Mediastinal Tumors . . . . . . ' . 100 

Mediate Auscultation ....... 21 

Mensuration 14 

Metallic Heart Sounds . .' 128 

Rales 54 

Tinkle ' . . 48 

Miliary Tuberculosis, Acute ...... 83 

Mitral Obstruction 154 

" Regurgitation 153 

" Stenosis 154 

Modification of Heart Sounds 130 

Movements of Heart . . 112 

Movements of Thorax, in Disease . . . . . 11 

" " " in Health 10 

Murmurs 145 



INDEX. 1S5 



Murmurs, Cause of ........ . 148 

" Combination of . . . . . . 157 

" Variability of 158 

Myoidema .......... 85 

CEdema, Pulmonary ........ 80 

Organs, Thoracic, Position of ..... . 4 

Origin of Rales ......... 57 

Pain, Lack of Expansion from ...... 11 

Palpation .......... 12 

of Heart 117 

Paralysis of Heart 135 

Pectoriloquy ......... 51 

Percussion, Analysis of Sounds . . . . . . 32 

" Auscultatory ....... 137 

" in Disease ....... 41 

" in Health 19 

of Heart 118 

" Position for ....... 15 

" Respiratory ....... 43 

" Rules for ....... 16 

Pericardial Murmurs .... .... 146 

Pericardial-Pleural Murmurs # 147 

Pericarditis ......... 160 

Pericardium, Adherent ....... 163 

Phthisis 83 

Pigeon Breast ......... 9 

Pitch . . ' 34 

" Modified by Respiration ...... 34 

" of Murmurs . . . . . . . . 151 

Pleural Murmurs . . . . . . . . . 147 

Pleurisy, Fibrinous ........ 71 

" with Effusion ....... 73 

Pleuritic Friction Sounds 55 

Pneumothorax ......... 77 

Pneumonia, Lobar ........ 68 



1 86 INDEX. 



PAGE 

Pneumonia, Lobular ........ 70 

Presystolic Murmur 154 

Prolonged Expiration 46 

Propagation of Murmurs 151 

Puerile Respiration . 38 

Pulmonary Systolic Murmur 154 

" Regurgitation ....... 155 

" Resonance . 18 

Pulse 174 

Quality of Sound ........ 32 

" " " in Murmurs 151 

Rales, Coarse 54 

" Crepitant ........ 53 

"Dry 54 

" Gurgling 54 

" Moist 54 

" Origin of 57 

" Sibilant 54 

" Sonorous 54 

" Subcrepitant 54 

Reduplication of Heart Sounds ...... 135 

Regional Percussion in Health ...... 19 

Relative Position of Valves ...... 108 

Resistance, Sense of, in Percussion ..... 16 

Resonance, Unison ........ 36 

Respiration ......... 37 

" in Children ......'. 10 

" in Disease 44 

" in Men 10 

in Women ....... 10 

" Modified by Deformity 39 

" Play of Lung in 4 

Respiratory Percussion 43 

Retraction of Chest-Wall . . . . . . . 11 

Rhythm . 32 



INDEX. 187 

PAGE 

Rhythm of Murmurs 151 

Saliva, Sound from Swallowing ...... 57 

Scapular Region ........ 4 

Sibilant Rales ......... 54 

Sonorous Rales ......... 54 

Sounds, Adventitious ........ 57 

" Duration of . . . . . . . . 32 

" Inflection of . . . . . . . . 121 

" Intensity of . . . . . . . . 32 

" Modified by Stethoscope ..... 147 

Pitch of 34 

" Quality of . . . ... . . 32 

" Rhythm of ....... 32 

" Transmission of . . . . . . -33, 146 

Sphygmograph 176 

Stenosis, Aortic . 152 

" Mitral ......... 154 

" Pulmonary ........ 154 

" Tricuspid ........ 156 

Sternal Resonance ........ 19 

Stethoscope ......... 21 

" Differential ....... 26 

" Modified Chest-Piece ..... 23 

" Value of ....... 30 

Stomach, Metallic Tinkle from . . . . . . 57 

Subclavian Artery, Position of . . . . . . 6, 8 

Subcrepitant Rales ........ 54 

Succussion .......... 15 

Suppressed Respiration ....... 46 

" Vocal Resonance ...... 50 

Supra-Clavicular Region ....... 2 

Supra-Scapular Region ....... 4 

Supra-Sternal Region ....... 3 

Sussurus, Muscular ........ 57 

Table of Averages of Hearts ...... 143 



1 88 INDEX. 

PAGE 

Thoracic Organs, Position of ..... 4 

' ' Aneurism . . . . . . . • . 167 

Tinkling, Metallic 48 

Tricuspid Insufficiency . . . . . . . 156 

". Obstruction ....... 156 

Tubercle Bacilli ......... 96 

Tubercular Phthisis ........ 83 

Tuberculosis, Acute ........ 83 

Tubular Breathing, see Bronchial Breathing. 

Tumors, Mediastinal ........ 100 

Tympanitic Resonance ....... 19, 42 

Unison Resonance ......... 36 

Upper Sternal Region ....... 3 

Valves, Position of ....... 108 

Valvular Murmurs, Theory of . . . ■ . . 148 

Veins, Congestion of . . . . . . . . 173 

" Pulsation of ....... . 173 

Venous Murmurs ........ 173 

Ventricles, Position of . 106 

Vesico-Tympanitic Resonance 79 

Vesicular Breathing 38 

Vocal Fremitus 13 

" " Cause of 40 

" " in Disease ....... 53 

" Resonance ........ 39 

" " in Disease ..... : 5° 

Water-Hammer Pulse 176 

Wavy Respiration ........ 47 

Weak Respiration ........ 46 

Whisper 39 

" in Disease 52 



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